Expression of the Calcium-Sensing Receptor on Normal and Abnormal Parathyroid and Thyroid Tissue.

INTRODUCTION: Current imaging techniques have several limitations in detecting parathyroid glands. We have investigated the calcium-sensing receptor (CaSR) as a potential target for specifically labeling parathyroid glands for radiologic detection. For accurate imaging it is vital that a large differential expression exists between the target tissue and adjacent structures. We sought to investigate the relative abundance of the CaSR in normal and abnormal parathyroid tissue, as well as normal and abnormal thyroid. METHODS: Existing clinical specimens were selected that represented a wide variety of pathologically and clinically confirmed malignant and benign thyroid and parathyroid specimens. Sections were stained for the CaSR using immunohistochemistry and scored for intensity and abundance of expression. (H score = intensity scored from 0 to 3 multiplied by the % of cells at each intensity. Range 0-300). RESULTS: All parathyroid specimens expressed the CaSR to a high degree. Normal parathyroid had the highest H score (271, s.d. 25.4). Abnormal parathyroid specimens were slightly lower but still much higher than normal thyroid (H score 38.3, s.d. 23.3). Medullary thyroid cancer also expressed the CaSR significantly higher than normal thyroid (H score 182, s.d. 69.1, P < 0.001) but below parathyroid levels. Hürthle cell carcinoma expressed the CaSR to a lesser degree but higher than normal thyroid (H score 101, s.d. 46.4, P = 0.0037). CONCLUSIONS: The CaSR is differentially expressed on parathyroid tissue making it a feasible target for parathyroid imaging. False positives might be anticipated with medullary and Hürthle cell cancers.

Recurrent multinodular goitre and primary hyperparathyroidism due to adenoma arising in a parathyroid autotransplant more than 20 years after near-total thyroidectomy.

The patient is a female in her 60s with a remote history of a near-total thyroidectomy in 1997 for multinodular goitre. At the initial operation, she sustained a left recurrent laryngeal nerve injury. A devascularised parathyroid gland was autotransplanted into the right sternocleidomastoid muscle. She had been off of thyroid hormone for long periods, and her most recent levothyroxine requirement had fallen to only 25 mcg daily. The patient presented more than 20 years after her thyroidectomy with hoarseness, fatigue and dyspnoea. Laboratory studies suggested primary hyperparathyroidism. Imaging demonstrated bilateral pulmonary emboli and bulky thyroid tissue extending into her mediastinum. She underwent a completion thyroidectomy with the removal of a parathyroid adenoma arising in the autotransplanted parathyroid. This case illustrates the possibility of regrowth of benign thyroid tissue after thyroidectomy. In addition, to our knowledge, this is the first case report of a parathyroid adenoma arising from autotransplantation of a normal parathyroid.

Alcohol consumption and socioeconomic status associated with the risk of kidney cancer in a large Australian cohort study.

PURPOSE: Studies have shown an inverse association between alcohol consumption and kidney cancer risk. We postulate that this inverse association may be further influenced by other risk factors. METHODS: We used an Australian cohort, the 45 and Up Study, recruited between 2005 and 2009 to investigate the association between alcohol consumption, and other potential risk factors and kidney cancer incidence. The median follow-up was 5.4 years. RESULTS: Of the 267,357 participants aged ≤45 years living in New South Wales, 497 were diagnosed with kidney cancer. There was a significant inverse association between alcohol consumption and risk of kidney cancer (P = .027), and a significant inverse dose-response relationship (P = .011). There was a significant interaction between alcohol consumption and socioeconomic status (P interaction = .001). Participants residing in higher socioeconomic areas (the two most advantaged quintiles) who consumed 8-10 drinks or greater than 10 drinks per week, respectively, had a lower risk of kidney cancer compared to the group who consumed 1-4 drinks per week (hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.15-0.76, HR 0.51, 95% CI 0.31-0.83) with a dose-response trend of HR 0.62 (95% CI 0.42-0.93) per 7 drink increase in weekly alcohol consumption. CONCLUSIONS: There could be an inverse association between alcohol consumption and risk in those residents in higher socioeconomic areas.

Penile pressure ulcers secondary to indwelling catheter and prone positioning for COVID-19 infection.

Prone ventilation is an effective and increasingly utilised tool in the management of Acute Respiratory Distress Syndrome (ARDS), a common sequela of COVID-19 infection. However, its use is associated with a significant risk of pressure ulcers. We report a unique case of prone positioning, catheter-related penile pressure ulcer. Clinical awareness, early recognition and regular repositioning is crucial in the prevention of this complication.

Expanding the role of PSMA PET in active surveillance.

INTRODUCTION: Accurate grading at the time of diagnosis is fundamental to risk stratification and treatment decision making, particularly for men being considered for Active Surveillance (AS). With the introduction of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) there has been considerable improvement in sensitivity and specificity for the detection and staging of clinically significant prostate cancer. Our study aims to determine the role of PSMA PET/CT in men with newly diagnosed low or favourable intermediate risk prostate cancer to better select men for AS. METHOD: This is a retrospective single centre study performed from January 2019 and October 2022. This study includes men identified from electronic medical record system who had undergone a PSMA PET/CT following newly diagnosed low or favourable-intermediate risk prostate cancer. Primary outcome was to assess the change in management for men being considered for AS following PSMA PET/CT results on the basis of PSMA PET characteristics. RESULTS: In total, there were 11 of 30 men (36.67%) who were assigned management by AS and 19 of 30 men (63.33%) who had definitive treatment. 15 of the 19 men that needed treatment had concerning features on PSMA PET/CT results. Of the 15 men with concerning features on PSMA PET, 9 (60%) men were found to have adverse pathological features on final prostatectomy features. CONCLUSION: This retrospective study suggests that PSMA PET/CT has potential to influence the management of men with newly diagnosed prostate cancer that would otherwise be appropriate for active surveillance.

Clear cell adenocarcinoma of the prostatic urethra with metachronous prostate adenocarcinoma.

A 70-year-old male underwent a Transurethral Resection of Prostate for the management of obstructive voiding symptoms. On cystoscopy, papillary frond-like lesions up to 2cm in size were encountered, overlying the right side of the prostatic urethra. Histopathology from the resection revealed clear cell adenocarcinoma (CCA) of the prostatic urethra. Primary clear cell adenocarcinoma of the prostatic urethra is exceedingly rare, with as few as 9 cases reported. We review the literature for its oncogenesis, discuss the histopathological features for diagnosis and report on our surgical management and outcome.

Practical Guide to Quality Control in Surgical Trials.

This Guide to Statistics and Methods outlines the elements of clinical trial quality control that are important to safeguarding data integrity and addressing the unique challenges of procedural trials.

Shared Autonomy to Reduce Sedentary Behavior Among Sit-Stand Desk Users in the United States and India: Web-Based Study.

BACKGROUND: Fitness technologies such as wearables and sit-stand desks are increasingly being used to fight sedentary lifestyles by encouraging physical activity. However, adherence to such technologies decreases over time because of apathy and increased dismissal of behavioral nudges. OBJECTIVE: To address this problem, we introduced shared autonomy in the context of sit-stand desks, where user input is integrated with robot autonomy to control the desk and reduce sedentary behavior and investigated user reactions and preferences for levels of automation with a sit-stand desk. As demographics affect user acceptance of robotic technology, we also studied how perceptions of nonvolitional behavior change differ across cultures (United States and India), sex, familiarity, dispositional factors, and health priming messages. METHODS: We conducted a web-based vignette study in the United States and India where a total of 279 participants watched video vignettes of a person interacting with sit-stand desks of various levels of automation and answered questions about their perceptions of the desks such as ranking of the different levels of automation. RESULTS: Participants generally preferred either manual or semiautonomous desks over the fully autonomous option (P<.001). However, participants in India were generally more amenable to the idea of nonvolitional interventions from the desk than participants in the United States (P<.001). Male participants had a stronger desire for having control over the desk than female participants (P=.01). Participants who were more familiar with sit-stand desks were more likely to adopt autonomous sit-stand desks (P=.001). No effects of health priming messages were observed. We estimated the projected health outcome by combining ranking data and hazard ratios from previous work and found that the semiautonomous desk led to the highest projected health outcome. CONCLUSIONS: These results suggest that the shared autonomy desk is the optimal level of automation in terms of both user preferences and estimated projected health outcomes. Demographics such as culture and sex had significant effects on how receptive users were to autonomous intervention. As familiarity improves the likelihood of adoption, we propose a gradual behavior change intervention to increase acceptance and adherence, especially for populations with a high desire for control.

The effect of COVID-19 on prostate cancer testing in Australia.

AIM: The effects of the COVID-19 pandemic on healthcare in Australia have yet to be fully determined. There are well documented decreases in the rates of screening and diagnostic testing for many cancers in 2020, with commensurate stage migration of cancers when they are eventually detected. We aimed to determine whether there was a decrease in the rate of prostate cancer (PC) screening and testing in Australia in 2020. METHOD: Data was extracted from the Department of Human Services (DHS) website for Medicare Benefits Schedule (MBS) item numbers for tests pertinent to detection of Prostate Cancer. This data is de-identified and publicly available. Data was analysed at both a national, and a state level. RESULTS: For 2020 nationwide the percentage change for prostate cancer testing was minor with 97% as many PSA tests, 99% as many prostate MRIs, and 105% as many prostate biopsies as the average for the preceding years. The differences were not significant (PSA tests p = 0.059 and prostate biopsies p = 0.109). The predicted values are fairly similar to both the average values for the preceding 5 years and the actual number of tests done in 2020. With exception of PSA tests in Victoria the actual number of tests performed was within the 95% Prediction Interval (performed: 167,426; predicted 171,194-196,699; p = 0.015). CONCLUSION: The current pandemic has had a widespread reach across Australia, with varying impact across each state and territory. Contrary to the trends across the world, our data suggest that during 2020 in Australia most areas remained unaffected in terms of prostate cancer testing excluding Victoria, which had statistically significant decrease in the number of PSA tests correlating with the extended lockdown that occurred in the state.

Chronic Fatigue After Thyroidectomy: A Patient-Centered Survey.

BACKGROUND: Fatigue after thyroidectomy is common, but there is a paucity of data regarding its prevalence and duration. We hypothesized that total thyroidectomy (TT) patients would have more long-term fatigue than thyroid lobectomy (TL) patients. METHODS: Statewide survey of thyroidectomy patients (2004-2017) was carried out. RESULTS: 281 patients completed the survey. 216 respondents (77%) had TT and 65 (23%) had TL. Within one year of surgery, 172 (61%) respondents recalled being troubled by new fatigue all, most, or some of the time. Total thyroidectomy patients were more likely to report new fatigue (69% vs. 44%, aOR 2.72, 95% CI 1.44 to 5.18). Of patients (n = 172) reporting new fatigue, 67 (39%) reported at least moderate improvement. Nineteen (28%) saw improvement within 1 year, 35 (52%) saw improvement in 1-2 years, and 11 (16%) saw improvement after 2 years. CONCLUSION: Long-term fatigue after TT can be debilitating, long-lasting, and less prevalent after TL.

Linear Predictive Coding for Acute Stress Prediction from Computer Mouse Movements.

Prior work demonstrated the potential of using the Linear Predictive Coding (LPC) filter to approximate muscle stiffness and damping from computer mouse movements to predict acute stress levels of users. Theoretically, muscle stiffness and damping in the arm can be estimated using a mass-spring-damper (MSD) biomechanical model. However, the damping frequency (i.e., stiffness) and damping ratio values derived using LPC were not yet compared with those from a theoretical MSD model. This work demonstrates that the damping frequency and damping ratio from LPC are significantly correlated with those from an MSD model, thus confirming the validity of using LPC to infer muscle stiffness and damping. We also compare the stress level binary classification performance using the values from LPC and MSD with each other and with neural network-based baselines. We found comparable performance across all conditions demonstrating LPC and MSD model-based stress prediction efficacy, especially for longer mouse trajectories.Clinical relevance- This work demonstrates the validity of the LPC filter to approximate muscle stiffness and damping and predict acute stress from computer mouse movements.

ACR Appropriateness Criteria® Parathyroid Adenoma.

Hyperparathyroidism is defined as excessive parathyroid hormone production. The diagnosis is made through biochemical testing, in which imaging has no role. However, imaging is appropriate for preoperative parathyroid gland localization with the intent of surgical cure. Imaging is particularly useful in the setting of primary hyperparathyroidism whereby accurate localization of a single parathyroid adenoma can facilitate minimally invasive parathyroidectomy. Imaging can also be useful to localize ectopic or supernumerary parathyroid glands and detail anatomy, which may impact surgery. This document summarizes the literature and provides imaging recommendations for hyperparathyroidism including primary hyperparathyroidism, recurrent or persistent primary hyperparathyroidism after parathyroid surgery, secondary hyperparathyroidism, and tertiary hyperparathyroidism. Recommendations include ultrasound, CT neck without and with contrast, and nuclear medicine parathyroid scans. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A diagnostic and management conundrum in a rare case of a small renal mass UTUC with IVC and bilateral renal vein tumour thrombus.

Upper Tract Urothelial Carcinomas (UTUC) are generally uncommon, accounting for approximately 5% of all urinary tract tumours. This report describes a unique Case of a 52-year-old-male with no known risk factors or symptoms of UTUC, who presented with bilateral sub-massive pulmonary embolus (PE). Subsequent computed tomography (CT) demonstrated a small (<2cm) right cortical based mass a discordant venous tumour thrombus (VTT) extending in the IVC, up to the level of the hepatic vein and bilateral renal veins. The patient had surgical excision in the form of right radical nephroureterectomy, IVC resection with bovine pericardial graft reconstruction and left renal autotransplant.

A comparison of prostate cancer prediction models in men undergoing both magnetic resonance imaging and transperineal biopsy: Are the models still relevant?

OBJECTIVE: To externally validate and compare the performance of the European Randomized Study of Screening for Prostate Cancer risk calculator 3/4 (ERSPC-RC3/4), the Prostate Biopsy Collaborative Group risk calculator (PBCG-RC) and the van Leeuwen model to determine which prediction model would perform the best in a contemporary Australian cohort undergoing transperineal (TP) biopsy. MATERIALS AND METHODS: A retrospective review identified all patients undergoing TP biopsy across two centres. Of the 797 patients identified, 373 had the data required to test all three risk calculators. The probability of high-grade prostate cancer, defined as International Society of Urological Pathology Grade Group >1, was calculated for each patient. For each prediction model discrimination was assessed using area under the receiver-operating characteristic curve (AUC), calibration using numerical and graphical summaries, and net benefit using decision curve analysis. RESULTS: Assessment of model discrimination for detecting high-grade prostate cancer showed AUCs of 0.79 (95% confidence interval [CI] 0.74-0.84) for the ERSPC-RC3/4, 0.81 (95% CI 0.77-0.86) for the van Leeuwen model, and 0.68 (95% CI 0.63-0.74) for the PBCG-RC, compared to 0.58 (95% CI 0.52-0.65) for prostate-specific antigen alone. The ERSPC-RC3/4 was the best calibrated in the moderate-risk range of 10-40%, whilst the van Leeuwen model was the best calibrated in the low-risk range of 0-10%. The van Leeuwen model demonstrated the greatest net benefit from 10% risk onwards, followed closely by the ERSPC-RC3/4 and then the PBCG-RC. CONCLUSION: The ERPSC-RC3/4 demonstrated good performance and was comparable to the van Leeuwen model with regard to discrimination, calibration and net benefit for an Australian population undergoing TP prostate biopsy. It is one of the most accessible risk calculators with an easy-to-use online platform, therefore, we recommend that Australian urologists use the ERSPC-RC3/4 to predict risk in the clinical setting.

Use and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism in the Medicare population.

BACKGROUND: Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults. METHODS: We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006-2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy. RESULTS: We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71-82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy. CONCLUSION: Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.