Giant Parathyroid Adenoma: A Case Report.

Parathyroid adenomas rarely weigh more than 4 grams. Our patient had a 5.3-gram adenoma causing bilateral knee pain limiting mobility, constipation, low back pain, and frontal headache. Presenting with calcium of greater than 17 mg/dl, the patient was treated with two rounds of hemodialysis, calcitonin, Zoledronate, and aggressive IV hydration to decrease calcium levels before parathyroidectomy. The patient then went on to develop the hungry bone syndrome, which was treated with calcium carbonate and calcitriol. This rare giant parathyroid adenoma presents a unique opportunity to learn about the pathogenesis and treatment of longstanding hyperparathyroidism causing hypercalcemia-associated symptoms and hungry bone syndrome after parathyroidectomy.

The Effects of Radioiodine Therapy on the Recovery of Parathyroid Function in Patients with Protracted Hypoparathyroidism after Total Thyroidectomy for Papillary Thyroid Carcinoma.

BACKGROUND: To determine the effect of 131I treatment on postoperative parathyroid function and the timing of recovery of parathyroid function (RPF) in patients with protracted hypoPT. METHODS: 260 patients with papillary thyroid cancer (PTC) were retrospectively analyzed, including 166 patients treated with radioactive iodine-131 (131I) classified into the 131I group and 94 patients without 131I treatment classified into the control group. Data on clinicopathological characteristics, demographics, dose and interval time of 131I treatment, number of parathyroid glands remaining in situ (PGRIS), occurrence of hypoPT, duration of RPF, preoperative and postoperative levels of Ca and PTH were collected. RESULTS: The patients in the 131I group showed a higher persistent hypoPT rate than those in the control group (p = 0). The PGRIS and total number of PG were significantly higher in patients who recovered from protracted HypoPT (p = 0.02; p = 0.03). PGRIS and 131I treatment [1 ∼ 2 VS 0, p = 0.03, OR 3.19; 3 ∼ 4 VS 0, p = 0.02, OR3.62; p = 0.02, OR 1.98, respectively] were independent factors influencing postoperative persistent hypoPT. The timing of RPF differed significantly for patients in the control group compared to those in the 131I group [p = 0.00]. CONCLUSIONS: We found that 131I treatment significantly prolonged the RPF of patients with protracted hypoPT and caused late RPF (even beyond 12 months). The diagnosis of "permanent" hypoPT should be cautiously made at least 12 months after surgery, especially in patients who receive 131I treatment.

Use of Parathyroid Function Index and Wisconsin Index to Differentiate Primary Hyperparathyroidism From Secondary Hyperparathyroidism: A Case-Control Study.

INTRODUCTION: Patients with primary hyperparathyroidism (PHPT) can be asymptomatic or have a normal calcium level (NHPT). Patients with 25(OH) vitamin D insufficiency, on the other hand, may present with a similar presentation. In regions where 25(OH) vitamin D deficiency is common, patients are usually diagnosed with secondary hyperparathyroidism (SHPT). Therefore, it is necessary to separate PHPT and NHPT from SHPT. Parathormone and calcium values are used for differentiation in the clinic. The predictive value of the newly developed parathyroid function test (PFindex), which previously had a high diagnostic value, was evaluated in this patient population in our investigation. METHODS: The study comprised 163 PHPT and NHPT patients with pathological confirmation and 56 SHPT patients. The PHPT, NHPT, and SHPT properties were defined using PFindex. The diagnostic power of PFindex was investigated using a receiver operating characteristic (ROC) curve of the results assessed in three groups. RESULTS: The PHPT group had the highest PFindex (1365.4±784.6) compared to the other two groups (NHPT: 723.5±509.4; SHPT:227.2±49.9, all p < 0.001). A PFindex threshold of 327.8 yielded 91.9% and 90.9% sensitivity and specificity rates for distinguishing PHPT and NHPT from SHPT, respectively. CONCLUSION: PFindex gave the outstanding diagnostic capacity to distinguish PHPT from SHPT due to our research. This straightforward tool can assist in making quick decisions about vitamin D therapy or surgery for PHPT.

The effect of modified Miccoli surgery in the treatment of patients with benign thyroid diseases and its influence on the postoperative aesthetic degree of scar score and the expression of pain factors / 中国医师进修杂志

Objective:To investigate the effect of modified Miccoli surgery in the treatment of patients with benign thyroid disease and its intervention on the postoperative aesthetic degree of scar score and the expression of pain factors.Methods:The clinical data of 114 patients with benign thyroid diseases in Hankou Hospital from February 2018 to February 2020 were collected, 57 cases with traditional open thyroid surgery were enrolled in the open group, and 57 cases with modified Miccoli surgery were enrolled in the modified group. The surgery related indicators, postoperative recovery indicators, complications and preoperative, postoperative 1, 3 d serum pain factors substance P (SP), β-endorphin (β-EP), dynorphin ( DYN), immune function indexes CD 3+, CD 4+, CD 8+, parathyroid function related indexes parathyrotropic hormone(PTH), blood calcium, 3 months and 6 months after surgery of observer scar evaluation scale (OSAS), Vancouver scar scale (VSS) scores were compared between the two groups. Results:The length of incision, recovery time of neck movement, and hospital stay and the intraoperative blood loss were lower than those in the open group: (2.2 ± 0.4) cm vs. (6.5 ± 0.7) cm, (19.6 ± 4.8) h vs. (28.2 ± 7.8) h, (4.8 ± 1.4) d vs. (7.1 ± 1.8) d, (21.9 ± 5.1) ml vs. (39.5 ± 7.0) ml, the differences were statistically significant ( P<0.05). The levels of serum SP, β-EP and DYN in the modified group were lower than those in the open group at 1 and 3 d after operation: 1 d after surgery:(87.40 ± 12.25) ng/L vs. (114.96 ± 15.79) ng/L, (149.34 ± 21.49) ng/L vs.(192.15 ± 26.43) ng/L, (1.14 ± 0.21) mg/L vs. (1.59 ± 0.30) mg/L; 3 d after surgery: (80.18 ± 10.79) ng/L vs.(96.24 ± 12.36) ng/L, (137.46 ± 18.57) ng/L vs. (168.24 ± 21.50) ng/L, (0.94 ± 0.16) mg/L vs. (1.27 ± 0.25) mg/L, the differences were statistically significant ( P<0.05). The levels of CD 3+ and CD 4+ in the modified group were higher than those in the open group at 1 and 3 d after the operation, and the CD8+ level was lower than that of the open group: 1 d after surgery: 0.597 ± 0.053 vs. 0.542 ± 0.049, 0.382 ± 0.041 vs. 0.362 ± 0.036, 0.308 ± 0.048 vs. 0.332 ± 0.060; 3 d after surgery: 0.615 ± 0.060 vs. 0.580 ± 0.055, 0.408 ± 0.051 vs. 0.385 ± 0.046, 0.290 ± 0.038 vs. 0.317 ± 0.045, and the differences were statistically significant ( P<0.05). The levels of serum PTH and blood calcium in the modified group were higher than those in the open group at 1 and 3 d after operation: 1 d after surgery: (29.12 ± 6.58) ng/L vs. (20.67 ± 5.14) ng/L, (1.86 ± 0.22) mmol/L vs. (1.59 ± 0.10) mmol/L; 3 d after surgery: (36.39 ± 7.65) ng/L vs. (24.08 ± 5.97) ng/L, (2.03 ± 0.18) mmol/L vs. (1.72 ± 0.14) mmol/L, the differences were statistically significant ( P<0.05). The OSAS and VSS scores of the modified group were lower than those of the open group at 3 and 6 months after surgery: 3 months after surgery: (15.9 ± 3.3) scores vs. (24.7 ± 6.9) scores, (4.4 ± 1.5) scores vs. (8.1 ± 3.2) scores; 6 months after surgery: (10.3 ± 2.7) scores vs. (17.1 ± 5.4) scores, (3.3 ± 1.2) scores vs. (6.9 ± 2.4) scores, the differences were statistically significant ( P<0.05). The incidence of postoperative complications in the modified group was lower than that in the open group: 3.51%(2/57) vs. 15.79%(9/57), the difference was statistically significant ( P<0.05). Conclusions:The application of modified Miccoli surgery in patients with benign thyroid diseases can reduce the length of the incision, reduce the impact on postoperative pain stress, immune function, and parathyroid function, speed up the process of postoperative recovery, improve the appearance of postoperative aesthetic degree of scar, and reduce the risk of complications.

Outcome of parathyroid function after total thyroidectomy when calcium supplementation is administered routinely versus exclusively to symptomatic patients: A prospective randomized clinical trial.

PURPOSE: Current guidelines for calcium supplementation for parathyroid function recovery after thyroidectomy are based on low-quality evidence. The present trial compared the effects of oral calcium and vitamin D supplementation on the recovery of parathyroid function when administered routinely or exclusively to symptomatic patients. METHODS: This prospective, randomized, open-label clinical trial analyzed 203 patients who underwent total thyroidectomy and developed hypoparathyroidism on postoperative day 1 (POD1) with median age of 41 years and proportion of women of 77.8%. Participants were randomized to group A (calcium and vitamin D supplementation administered only to symptomatic patients) and group B (routine supplementation). The primary outcome was the incidence of protracted hypoparathyroidism in the two groups. Secondary outcomes included risk factors for postoperative protracted hypoparathyroidism and the incidence of symptomatic hypocalcemia. RESULTS: The incidence of protracted hypoparathyroidism was not significantly different between group A and group B (11 of 99 vs. 17 of 104, P = 0.280). Parathyroid hormone (PTH) in group B exhibited a better recovery tendency. The incidence of postoperative symptomatic hypocalcemia in group B was significantly lower than group A (26.92% vs. 42.42%, P = 0.020). Independent factors predicting protracted hypoparathyroidism included sex, preoperative serum calcium, and POD1 PTH. CONCLUSION: Calcium and vitamin D supplementation administered exclusively to symptomatic patients achieved the same effect on protracted hypoparathyroidism as routine supplementation. However, routine supplementation significantly reduced postoperative hypocalcemia. Extra attention is necessary in female patients with high preoperative serum calcium and patients with low POD1 PTH. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR), ChiCTR1900022194. Registered March 30, 2019.

Effect of Postoperative High-Concentration Oxygen on Recovery After Thyroid Surgery: A Prospective, Open, Randomized, Controlled Study.

Objective: To investigate the effectiveness of high-concentration oxygen on the improvement of throat symptoms and voice changes after thyroid surgery and its protection of the parathyroid function. Methods: A total of 600 patients undergoing thyroid surgery who met the inclusion criteria were randomly divided into the experimental group (n = 300) and the control group (n = 300) by using a random number generator. The patients in the experimental group underwent high-oxygen treatment [FiO280 (8 L/min)] for 6 continuous hours after returning to the ward after surgery. The patients in the control group underwent low-oxygen treatment [FiO230 (2 L/min)] for 6 continuous hours after returning to the ward after surgery. Results: The postoperative incision pain score of patients in the experimental group was significantly better than that in the control group at 6 h (1.07 ± 0.80 VS 1.23 ± 0.95, P=0.031) and 12 h (1.08 ± 0.64 VS 1.20 ± 0.73, P=0.041). The postoperative throat pain score of the patients in the experimental group was significantly better than that of the control group at 6 h (1.40 ± 0.85 VS 1.59 ± 0.97, P=0.011) and 12 h (1.40 ± 0.85 VS 1.59 ± 0.97, P=0.019). The PONV score of the patients in the experimental group was significantly better than that of the control group at 12 h (0.09 ± 0.19 VS 0.14 ± 0.37, P=0.024). The Voice Handicap Index score of the patients in the experimental group was significantly better than that of the control group at 24 h (2.89 ± 5.92 VS 4.10 ± 6.31, P=0.017), 36 h (2.46 ± 5.06 VS 3.43 ± 5.97, P=0.035), and 48 h (2.46 ± 5.06 VS 3.43 ± 5.97, P=0.032). Conclusion: High-concentration oxygen can alleviate PONV and pain after thyroid surgery, with less severe voice changes potentially. However, its effects on swallowing function, and parathyroid function need to be further verified. Clinical Trial Registration Number: ChiCTR-IOR-17012765 (China Clinical Trial Registry clinical trial registration center [http://www.chictr.org.cn/index.aspx).

Duration of Parathyroid Function Recovery in Patients With Protracted Hypoparathyroidism After Total Thyroidectomy for Papillary Thyroid Carcinoma.

Purpose: The aim of the present study is to investigate the time to recovery of parathyroid function in patients with protracted hypoparathyroidism at 1 month after total thyroidectomy of papillary thyroid carcinoma. Materials and Methods: Adult patients who underwent total thyroidectomy for papillary thyroid cancer were included. Cases of long-term hypoparathyroidism were studied for recovery of parathyroid function during the follow-up. The duration of recovery and associated variables were recorded. Results: Out of the 964 patients, 128 (13.28%) developed protracted hypoparathyroidism and of these, 23 (2.39%) developed permanent hypoparathyroidism and 105 (10.89%) recovered: 86 (8.92%) before 6 months, 11 (1.14%) within 6 and 12 months and 8 (0.83%) after 1 year follow-up. Variables significantly associated with the time to parathyroid function recovery were number of autotransplanted parathyroid glands (HR, 1.399; 95% CI, 1.060 - 1.846; P = 0.018), serum calcium concentration >2.07 mmol/L (Hazard ratio [HR], 1.628; 95% confidence interval [CI], 1.009 - 2.628; P = 0.046) and PTH level > 1.2 pmol/L (HR, 1.702; 95% CI, 1.083 - 2.628; P = 0.021) at 1 month postoperatively. Conclusion: Permanent hypoparathyroidism should not be diagnosed easily by time, since up to one-fifth of the patients will experience recovery after a period of 6 months and a few patients even beyond one year. The number of autotransplanted parathyroid glands is positively associated with the time to parathyroid function recovery.

mRNA Profiles of Porcine Parathyroid Glands Following Variable Phosphorus Supplies throughout Fetal and Postnatal Life.

Knowledge of gene expression profiles reflecting functional features and specific responsiveness of parathyroid glands (PTGs) contributes to understanding mineral homeostasis and parathyroid function in healthy and diseased conditions. The study aims to reveal effector molecules driving the maintenance of phosphorus (P) homeostasis and parathyroid hormone (PTH) responsiveness to variable P supply throughout fetal and postnatal life. In this study, a long-term dietary intervention was performed by keeping pig offspring on distinct mineral P levels throughout fetal and postnatal life. Respective adaptation processes of P homeostasis were assessed in mRNA profiles of PTGs and serum minerals. RNA sequencing data and resulting molecular pathways of PTGs showed that the PTH abundance is very strictly controlled via e.g., PIN1, CaSR, MAfB, PLC and PKA signaling to regulate PTH expression, stability, and secretion. Additionally, the observed dietary effects on collagen expression indicate shifts in the ratio between connective tissue and parenchyma, thereby affecting cell-cell contacts as another line of PTH regulation. Taken together, the mRNA profiles of porcine PTGs reflect physiological responses in-vivo following variable dietary P supplies during fetal and postnatal life. The results serve to evaluate a long-term nutrition strategy with implications for improving the mineral balance in individuals with pathological disorders.

Recovery of severely damaged parathyroid function after total thyroidectomy for thyroid cancer.

BACKGROUND: An extremely low parathyroid hormone (PTH) concentration after thyroidectomy may reflect the immediate severely damaged parathyroid function. The current study aimed to examine time-related changes of severely damaged parathyroid function on postoperative day 1 (SDPF-D1), which was here defined as serum PTH ≤1 pg/mL, and the risk factors of SDPF-D1. METHODS: This is a retrospective review of patients with thyroid cancer undergoing total thyroidectomy with or without central neck dissection (CND). The number of parathyroids preserved in situ, autotransplanted, or found in the final pathology was recorded and the corresponding parathyroid glands remaining in situ (PGRIS) score (PGRIS = 4 - parathyroids autotransplanted-parathyroids found in the final pathology) was calculated. Chronological changes of serum levels of PTH and total calcium were investigated for at least one year after surgery. RESULTS: One hundred and twenty-two of 344 patients included for analysis suffered from SDPF-D1. Patients with SDPF-D1 had a prolonged recovery in comparison with hypoparathyroidism patients without SDPF-D1, who fully recovered within 6 months after thyroidectomy. The PGRIS score in patients with permanent hypoparathyroidism was significantly lower than other patients with SDPF-D1who fully recovered. CONCLUSIONS: Most patients with SDPF-D1 could fully recover within one year after total thyroidectomy. Less parathyroids removed and autotransplanted contributed to a quick recovery of SDPF-D1.

New parathyroid function index for the differentiation of primary and secondary hyperparathyroidism: a case-control study.

BACKGROUND: Patients with primary hyperparathyroidism (PHPT) may be asymptomatic, and some may present with normocalcemic PHPT (NPHPT). Patients with vitamin D deficiency may also be asymptomatic, with normal calcium and elevated PTH concentrations. These latter patients are usually diagnosed with vitamin D deficiency-induced secondary hyperparathyroidism (VD-SHPT). Therefore, it is very difficult to distinguish PHPT and NPHPT from VD-SHPT based on calcium or PTH concentrations in clinical settings. In this case-control study, we aimed to verify the diagnostic power of a new parathyroid function index (PFindex = Ca*PTH/P). METHODS: This study enrolled 128 patients with surgically and pathologically confirmed PHPT, including 36 with NPHPT, at a hospital in West China between January 2009 and September 2017. Thirty-seven patients with VD-SHPT and 45 healthy controls were selected from the population of a cross-sectional epidemiological study as the SHPT and healthy groups, respectively. We used the PFindex to describe the characteristics of PHPT, NPHPT, and VD-SHPT.. Differences between the four groups were compared, and a receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic power of PFindex. RESULTS: The PHPT group had the highest PFindex (454 ± 430), compared to the other three groups (NPHPT: 101 ± 111; SHPT: 21.7 ± 6.38; healthy: 12.2 ± 2.98, all p < 0.001). A PFindex cut-off value of 34 yielded sensitivity and specificity rates of 96.9 and 97.6% and of 94.4 and 94.6% for the diagnoses of PHPT and NPHPT, respectively. The use of a PFindex > 34 to differentiate NPHPT from VD-SHPT yielded the highest positive likelihood ratio and lowest negative likelihood ratio. CONCLUSION: The PFindex provided excellent diagnostic power for the differentiation of NPHPT from VD-SHPT. This simple tool may be useful for guiding timely decision-making processes regarding the initiation of vitamin D treatment or surgery for PHPT.

Mechanisms Involved in the Relationship between Low Calcium Intake and High Blood Pressure.

There is increasing epidemiologic and animal evidence that a low calcium diet increases blood pressure. The aim of this review is to compile the information on the link between low calcium intake and blood pressure. Calcium intake may regulate blood pressure by modifying intracellular calcium in vascular smooth muscle cells and by varying vascular volume through the renin-angiotensin-aldosterone system. Low calcium intake produces a rise of parathyroid gland activity. The parathyroid hormone increases intracellular calcium in vascular smooth muscles resulting in vasoconstriction. Parathyroidectomized animals did not show an increase in blood pressure when fed a low calcium diet as did sham-operated animals. Low calcium intake also increases the synthesis of calcitriol in a direct manner or mediated by parathyroid hormone (PTH). Calcitriol increases intracellular calcium in vascular smooth muscle cells. Both low calcium intake and PTH may stimulate renin release and consequently angiotensin II and aldosterone synthesis. We are willing with this review to promote discussions and contributions to achieve a better understanding of these mechanisms, and if required, the design of future studies.

Significance of parathyroid hormone measurement in drainage liquid after thyroidectomy / 中华内分泌外科杂志

Objective To explore the significance of parathyroid hormone (PTH) measurement in drainage liquid after thyroid surgery,and to evaluate its relationship with parathyroid glands in situ.Methods Form Dec.2013 to Aug.2014,166 patients who underwent unilateral thyroidectomy were chosen as the research object.According to the number of parathyroid reserved in situ,patients were divided into group A0,group A1 and group A2.The levels of blood PTH and serum calcium were measured before and after operation,and postoperative PTH in drainage liquid was measured.Results The levels of postoperative blood PTH and serum calcium were lower than those before operation(P＜0.05).The difference of PTH level in drainage liquid in each group had statistical significance(P＜0.05).The level of drainage liquid PTH was highest in group A2,following group A1,and finally group A0.We found a positive correlation between the number of parathyroid glands protected in situ and the level of drainage liquid PTH.Conclusion Drainage liquid PTH measurement can be used to determine whether parathyroid gland is reserved in situ and its secretion function.

Effect of 131I 'clear residual thyroid tissue' after surgery on the function of parathyroid gland in differentiated thyroid cancer.

Thyroid cancer is a common malignant tumor of the endocrine glands. Although surgery is the optimal treatment utilized, the disease is characterized by recurrence and metastasis. The aim of the present study was to determine the effect of iodine-131 (131I) 'clear residual thyroid tissue' following surgery on the treatment of differentiated thyroid cancer (DTC) and its effect on the function of the parathyroid gland. A total of 160 patients diagnosed with DTC, who were consecutively admitted to our Hospital between June 2012 and June 2014 and underwent total thyroidectomy or subtotal resection, were included in the present study. After three months, the patients were administered 131I 'clear residual thyroid tissue' treatment and underwent a whole body scan after 1 week to determine whether 'clear residual thyroid tissue' treatment was successful or not. The treatment was repeated within 3 months if not successful. Of the 160 patients, 24 patients had cancer metastasis (15.0%). The average dose of 131I used for the first time was 6.4+1.2 GBq and the treatment was successful in 66 cases (41.3%). The average treatment time was 2.8±0.6 therapy sessions. The results showed that, prior to and following the first treatment and at the end of the follow up, levels of the parathyroid hormone, serum calcium and phosphorus were compared, and no statistically significant difference (P>0.05) was observed. There were 5 patients with persistent hypothyroidism and 8 patients with transient hypothyroidism. The levels of thyroglobulin were significantly decreased, and the difference was statistically significant (P<0.05). A total of 48 patients (30%) with hypothyroidism were identified. In conclusion, the results have shown that DTC resection and 131I 'clear residual thyroid tissue' treatment did not significantly impair the parathyroid function, thereby improving the treatment effect.

MEASUREMENT OF THYROID AND PARATHYROID FUNCTION IN CHILDREN WITH VITAMIN D-DEFICIENT RICKETS / 中华内分泌代谢杂志

Thyroid and parathyroid function were significantly changed in children with vitamin D-deficient rickets (VDR) of the early and the recovery stages in comparison with age-matched controls. Serum triiodothyronine (T3) and immunoreactive parathyroid hormone (iPTH) concentrations were significantly elevated (P