Community socioeconomic and urban-rural differences in emergency medical services times for suspected stroke in North Carolina.

OBJECTIVE: Our objectives were to describe time intervals of EMS encounters for suspected stroke patients in North Carolina (NC) and evaluate differences in EMS time intervals by community socioeconomic status (SES) and rurality. METHODS: This cross-sectional study used statewide data on EMS encounters of suspected stroke in NC in 2019. Eligible patients were adults requiring EMS transport to a hospital following a 9-1-1 call for stroke-like symptoms. Incident street addresses were geocoded to census tracts and linked to American Community Survey SES data and to rural-urban commuting area (RUCA) codes. Community SES was defined as high, medium, or low based on tertiles of an SES index. Urban, suburban, and rural tracts were defined by RUCA codes 1, 2-6, and 7-10, respectively. Multivariable quantile regression was used to estimate how the median and 90th percentile of EMS time intervals varied by community SES and rurality, adjusting for each other; patient age, gender, and race/ethnicity; and incident characteristics. RESULTS: We identified 17,117 eligible EMS encounters of suspected stroke from 2028 census tracts. The population was 65% 65+ years old; 55% female; and 69% Non-Hispanic White. Median response, scene, and transport times were 8 (interquartile range, IQR 6-11) min, 16 (IQR 12-20) min, and 14 (IQR 9-22) minutes, respectively. In quantile regression adjusted for patient demographics, minimal differences were observed for median response and scene times by community SES and rurality. The largest median differences were observed for transport times in rural (6.7 min, 95% CI 5.8, 7.6) and suburban (4.7 min, 95% CI 4.2, 5.1) tracts compared to urban tracts. Adjusted rural-urban differences in 90th percentile transport times were substantially greater (16.0 min, 95% CI 14.5, 17.5). Low SES was modesty associated with shorter median (-3.3 min, 95% CI -3.8, -2.9) and 90th percentile (-3.0 min, 95% CI -4.0, -2.0) transport times compared to high SES tracts. CONCLUSIONS: While community-level factors were not strongly associated with EMS response and scene times for stroke, transport times were significantly longer rural tracts and modestly shorter in low SES tracts, accounting for patient demographics. Further research is needed on the role of community socioeconomic deprivation and rurality in contributing to delays in prehospital stroke care.

Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina.

OBJECTIVES: Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality. METHODS: Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation. RESULTS: The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts. CONCLUSIONS: Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.

Pressure-Induced Amorphization of Diisopropylammonium Perchlorate Studied by Raman Spectroscopy and X-ray Diffraction.

Diisopropylammonium salts have drawn attention in recent years due to their room-temperature ferroelectric properties. Triclinic diisopropylammonium perchlorate (DIPAP) exhibits ferroelectricity at room temperature. We have carried out density functional theory calculations to assign the phonon modes in DIPAP. High-pressure Raman spectra of DIPAP are recorded up to ∼3 GPa. Discontinuity in the NH2 bending and stretching mode frequencies and the appearance of new bands at 0.7 GPa suggest a phase transition by a rearrangement in the hydrogen network. Broadening of lattice modes at 1.3-1.7 GPa indicates a loss of crystalline nature above 1.7 GPa. High-pressure synchrotron X-ray diffraction of DIPAP shows an isostructural phase transition at 0.6 GPa and confirms amorphization at 1.5 GPa that may lead to a loss of ferroelectricity above this pressure. The ambient phase becomes reversible after releasing the pressure. The bulk modulus of DIPAP is determined to be 16.5 GPa.

New High Pressure Phases of Energetic Material TEX: Evidence from Raman Spectroscopy, X-ray Diffraction, and First-Principles Calculations.

Samples of energetic material TEX (C6H6N4O8) are studied using Raman spectroscopy and X-ray diffraction (XRD) up to 27 GPa pressure. There are clear changes in the Raman spectra and XRD patterns around 2 GPa related to a conformational change in the TEX molecule, and a phase transformation above 11 GPa. The molecular structures and vibrational frequencies of TEX are calculated by density functional theory based Gaussian 09W and CASTEP programs. The computed frequencies compare well with Raman spectroscopic results. Mode assignments are carried out using the vibrational energy distribution analysis program and are also visualized in the Materials Studio package. Raman spectra of the high pressure phases indicate that the sensitivity of these phases is more than that of the ambient phase.

Rural-urban differences in emergency medical services bypass routing of stroke in North Carolina.

PURPOSE: Acute stroke is a serious, time-sensitive condition requiring immediate medical attention. Emergency medical services (EMS) routing and direct transport of acute stroke patients to stroke centers improves timely access to care. This study aimed to describe EMS stroke routing and transports by rurality in North Carolina (NC). METHODS: We conducted a retrospective study using existing data on EMS transports of suspected stroke patients in NC in 2019. The primary study outcome was EMS bypass of the nearest hospital for transport to a nonnearest hospital, determined by geographic information systems (GIS) analysis. Incident addresses were geocoded to census tracts and classified as urban, suburban, or rural by Rural-Urban Commuting Area codes. We compared the frequency of bypass and estimated additional transport times by urban, suburban, and rural incident locations. FINDINGS: Of 3666 patients, 1884 (51%) EMS transports bypassed the nearest hospital. Bypass occurred less often for rural EMS incidents (39%) compared to those in urban (57%) and suburban (63%) tracts. The estimated additional transport time for rural bypasses of nonendovascular-capable stroke centers for endovascular-capable stroke centers was a median of 25 min (interquartile range 13-33). CONCLUSIONS: Using GIS analysis, we found nearly half of EMS transports of suspected stroke patients in NC bypassed the nearest hospital, including noncertified hospitals and stroke centers. Bypasses occurred less often in rural areas, though incurred significantly longer transport times, compared to urban areas. These findings are important for regional stroke system planning, especially for improving rural access to acute stroke care.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Accuracy of the electronic health record's problem list in describing multimorbidity in patients with heart failure in the emergency department.

Patients with heart failure (HF) often suffer from multimorbidity. Rapid assessment of multimorbidity is important for minimizing the risk of harmful drug-disease and drug-drug interactions. We assessed the accuracy of using the electronic health record (EHR) problem list to identify comorbid conditions among patients with chronic HF in the emergency department (ED). A retrospective chart review study was performed on a random sample of 200 patients age ≥65 years with a diagnosis of HF presenting to an academic ED in 2019. We assessed participant chronic conditions using: (1) structured chart review (gold standard) and (2) an EHR-based algorithm using the problem list. Chronic conditions were classified into 37 disease domains using the Agency for Healthcare Research Quality's Elixhauser Comorbidity Software. For each disease domain, we report the sensitivity, specificity, positive predictive value, and negative predictive of using an EHR-based algorithm. We calculated the intra-class correlation coefficient (ICC) to assess overall agreement on Elixhauser domain count between chart review and problem list. Patients with HF had a mean of 5.4 chronic conditions (SD 2.1) in the chart review and a mean of 4.1 chronic conditions (SD 2.1) in the EHR-based problem list. The five most prevalent domains were uncomplicated hypertension (90%), obesity (42%), chronic pulmonary disease (38%), deficiency anemias (33%), and diabetes with chronic complications (30.5%). The positive predictive value and negative predictive value of using the EHR-based problem list was greater than 90% for 24/37 and 32/37 disease domains, respectively. The EHR-based problem list correctly identified 3.7 domains per patient and misclassified 2.0 domains per patient. Overall, the ICC in comparing Elixhauser domain count was 0.77 (95% CI: 0.71-0.82). The EHR-based problem list captures multimorbidity with moderate-to-good accuracy in patient with HF in the ED.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial.

OBJECTIVE: To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN: Pragmatic cluster randomized controlled trial (EMBED). SETTING: 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS: 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION: A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES: Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS: 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS: User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658642.

Half metallicity in Cr substituted Fe2TiSn.

Band structure tailoring has been a great avenue to achieve the half-metallic electronic ground state in materials. Applying this approach to the full Heusler alloy Fe2TiSn, Cr is introduced systematically at Ti site that conforms to the chemical formula [Formula: see text]Sn. Compositions so obtained have been investigated for its electronic, magnetic, and electrical transport properties with an aim to observe the half-metallic ferromagnetic ground state, anticipated theoretically for Fe2CrSn. Our experimental study using synchrotron X-ray diffraction reveals that only compositions with [Formula: see text] 0.25 yield phase pure L2[Formula: see text] cubic structures. The non-magnetic ground state of Fe2TiSn gets dramatically affected upon inclusion of Cr giving rise to a localized magnetic moment in the background of Ruderman-Kittel-Kasuya-Yosida (RKKY) correlations. The ferromagnetic interactions begin to dominate for x = 0.25 composition. Results of its resistivity and magnetoresistance (MR) measurement point towards a half-metallic ground state. The calculation of exchange coupling parameter, [Formula: see text], and orbital projected density of states that indicate a change in hybridization between 3d and 5p orbital, support the observations made from the study of local crystal structure made using the extended X-ray absorption fine structure spectroscopy. Our findings here highlight an interesting prospect of finding half-metallicity via band structure tailoring for wide application in spintronics devices.

Structural phase transition, equation of state and phase diagram of functional rare earth sesquioxide ceramics (Eu1-xLax)2O3.

The intriguing functional nature of ceramics containing rare earth sesquioxide (RES) is associated with the type of polymorphic structure they crystallize into. They prefer to be in the cubic, monoclinic or hexagonal structure in the increasing order of cation size, RRE. Since the functional properties of these ceramics varies with RRE, temperature and pressure, a systematic investigation delineating the cation size effect is indispensable. In the present work we report the structural stability and compressibility behaviour of the RES ceramics, (Eu1-xLax)2O3, of RESs with dissimilar structure and significant difference in cationic radii. The selected compositions of (Eu1-xLax)2O3 have been studied using the in-situ high pressure synchrotron X-ray diffraction and the structural parameters obtained through Rietveld refinement. The cubic structure, which is stable for 0.95 Å [Formula: see text] RRE [Formula: see text] Å at ambient temperature and pressure (ATP), prefers a cubic to hexagonal transition at high pressures. The biphasic region of cubic and monoclinic structure, which is stable for 0.98 Å [Formula: see text] RRE [Formula: see text] Å at ATP, prefers a cubic/monoclinic to hexagonal transition at high pressures. Further, in the biphasic region of monoclinic and hexagonal structure, observed for 1.025 Å [Formula: see text]RRE [Formula: see text] Å, the monoclinic phase is found to be progressing towards the hexagonal phase with increasing pressure. The pure hexagonal phase obtained for 1.055 Å [Formula: see text] RRE [Formula: see text] 1.10 Å is found to be structurally stable at high pressures. The bulk moduli are obtained from the Birch-Murnaghan equation of state fit to the compressibility data and its dependance on the cation size is discussed. The microstrain induced by the difference in cation size causes an internal pressure in the crystal structure leading to a reduction in the bulk modulus of [Formula: see text] and 0.6. A pressure-concentration (P-x) phase diagram upto a pressure of 25 GPa is constructed for (Eu1-xLax)2O3. This would provide an insight to the fundamental and technological aspects of these materials and the RESs in general.

Probing phase transition in VO2 with the novel observation of low-frequency collective spin excitation.

VO2 is well known for its first order, reversible, metal-to-insulator transition (MIT) along with a simultaneous structural phase transition (SPT) from a high-temperature metallic rutile tetragonal (R) to an insulating low-temperature monoclinic (M1) phase via two other insulating metastable phases of monoclinic M2 and triclinic T. At the same time, VO2 gains tremendous attention because of the half-a-century-old controversy over its origin, whether electron-electron correlation or electron-phonon coupling trigger the phase transition. In this regard, V1-xMgxO2 samples were grown in stable phases of VO2 (M1, M2, and T) by controlled doping of Mg. We have observed a new collective mode in the low-frequency Raman spectra of all three insulating M1, M2 and T phases. We identify this mode with the breather (singlet spin excitation) mode about a spin-Pierls dimerized one dimensional spin ½ Heisenberg chain. The measured frequencies of these collective modes are phenomenologically consistent with the superexchange coupling strength between V spin ½ moments in all three phases. The significant deviation of Stokes to anti-Stokes intensity ratio of this low-frequency Raman mode from the usual thermal factor exp(hʋ/KBT) for phonons, and the orthogonal dependency of the phonon and spinon vibration in the polarized Raman study confirm its origin as spin excitations. The shift in the frequency of spin-wave and simultaneous increase in the transition temperature in the absence of any structural change confirms that SPT does not prompt MIT in VO2. On the other hand, the presence of spin-wave confirms the perturbation due to spin-Peierls dimerization leading to SPT. Thus, the observation of spin-excitations resulting from 1-D Heisenberg spin-½ chain can finally resolve the years-long debate in VO2 and can be extended to oxide-based multiferroics, which are useful for various potential device applications.

Structural, optical and electronic properties of Ni1-x Co x O in the complete composition range.

Crystallographic and electronic structures of phase pure ternary solid solutions of Ni1-x Co x O (x = 0 to 1) have been studied using XRD, EXAFS and XAS measurements. The lattice parameter of the cubic rock-salt (RS) Ni1-x Co x O solid solutions increases linearly with increasing Co content and follows Vegard's law, in the complete composition range. A linear increase in the bond lengths (Ni/Co-O, Ni-Ni and Ni-Co) with "x", closely following the bond lengths determined from virtual crystal approximation (VCA), is observed, which implies that there is only a minimal local distortion of the lattice in the mixed crystal. The optical gap of the ternary solid solution determined from diffuse reflectivity measurements shows neither a linear variation with Co composition nor bowing, as observed in many ternary semiconductors. This trend in the variation of optical gaps is explained by probing the conduction band using XAS at the O K-edge. We have observed that the variation in the onset energy of the conduction band edge with "x" is very similar to the variation in the optical gap with "x", thus clearly indicating the dominant role played by the conduction band position in determining the optical gap. The variation in the intensities of the pre-edge peak in the XANES spectra measured at Ni and Co K-edges, and the L1/2 peak in XAS spectra measured at Ni and Co L-edges, is found to depend on the unoccupied O 2p-metal-(Ni/Co) 3d hybridized states and the bond lengths.

Atypical antipsychotics for people with both schizophrenia and depression.

BACKGROUND: Many people (up to 50%) with schizophrenia also have co-morbid depression. It has been suggested that new atypical antipsychotic drugs are beneficial for people with the two diagnoses. OBJECTIVES: To assess the effects of atypical antipsychotic drugs on people who have a diagnosis of both schizophrenia and depression. SEARCH STRATEGY: We searched the Cochrane Schizophrenia's Group Register (to March 2006). We supplemented this by citation searching and personal contact with authors and relevant pharmaceutical companies. SELECTION CRITERIA: We included randomised clinical trials of atypical antipsychotic drugs used specifically for the treatment of people with a diagnosis of both schizophrenia and depression. DATA COLLECTION AND ANALYSIS: We extracted data independently. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). MAIN RESULTS: We found 878 citations but were only able to include three studies (five reports). One trial found no significant difference between quetiapine and haloperidol for the outcome of 'less than 50% reduction in PANSS score' (n=180, RR 0.91 CI 0.8 to 1.0). Those allocated sulpiride had significantly lower depression scores compared with people given chlorpromazine (1 RCT, n=36, WMD CPRS -0.70 CI -1.2 to -0.2). Again, however, in the quetiapine versus haloperidol comparison, the continuous scoring did not highlight differences (1 RCT, n=180, WMD PANSS depression change -0.57 CI -1.4 to 0.30). When clozapine was compared with any other antipsychotic drug plus an antidepressant or placebo, clozapine constantly scored better on Hamilton scores (1 RCT, n=29, WMD vs antipsychotic + mianserin -5.53 CI -8.23 to -2.8; 1 RCT, n=32, WMD vs antipsychotic + meclobemide -4.35 CI -6.7 to -2.03; 1 RCT, n=33, WMD vs antipsychotic + placebo -6.35 CI -8.6 to -4.1). AUTHORS' CONCLUSIONS: There are too few data to guide patients, carers, clinicians or policy makers. Current practice has to be guided by evidence other than that derived from randomised trials and more trials in this important area are indicated.

Comparative studies on adsorptive removal of phenol by three agro-based carbons: equilibrium and isotherm studies.

The present study deals with the adsorption of phenol on carbon-rich black gram husk (BGH), green gram husk (GGH), and rice husk (RH). All these agro-wastes were collected from the local mills and physico-chemical treatments were carried out to improve their adsorption capacity. Batch studies were performed to evaluate the effect of various experimental parameters such as initial pH, contact time, adsorbent dosage, and initial phenol concentration (C(0)) of 100mg/l. Optimum conditions for phenol removal were found to be at pH 5.1 (in the range 2-12), an adsorbent dosage of 0.5 g/l of solution and for an equilibrium time of 6h. Equilibrium isotherms for the adsorption of phenol on BGH, GGH, and RH were analyzed by Freundlich, Langmuir, Temkin, Redlich-Peterson, and Dubinin-Radushkevich isotherm models. Redlich-Peterson isotherm was found to be the best representative for phenol-sorption on all the three adsorbents studied.

The recycling of autoclaved autografts in mandibular reconstruction: case report and review of literature.

Removal of pathological lesions from the mandible can leave a disfiguring appearance in addition to compromising the function of speech and mastication. It therefore becomes imperative to replace the lost part with bone grafts. Autogenous bone grafts-vascularised and non-vascularised, have been in vogue for the same. The probability of using the same resected bone after removal of all pathology has been done for a long time with mixed results in terms of uptake and viability. This paper presents a case of the use of autoclaved resected bone being used for reconstructing the mandible.

Structural investigations in BaFe(2-x)Ru(x)As2 as a function of Ru and temperature.

We present the results of synchrotron X-ray diffraction (XRD) measurements on powdered single-crystal samples of BaFe(2-x)Ru(x)As2, as a function of Ru content, and as a function of temperature, across the spin-density wave transition in BaFe(1.9)Ru(0.1)As2. The Rietveld refinements reveal that with Ru substitution, while the a-axis increases, the c-axis decreases. In addition, the variation of positional coordinates of As (z(As)), the Fe-As bond length and the As-Fe-As bond angles have also been determined. In the sample with x = 0.1, temperature-dependent XRD measurements indicate that the orthorhombicity shows the characteristic increase with a decrease in temperature, below the magnetic transition. It is seen that the c-axis, the As-Fe-As bond angles, Fe-As bond length and positional coordinates of the As show definite anomalies close to the structural transition. The observed anomalies in structural parameters are analysed in conjunction with restricted geometric optimization of the structure using ab initio electronic structure calculations.

Parathyroid adenoma in a young male with multiple fractures and varied clinical features.

Primary hyperparathyroidism is due to parathyroid adenoma (80-85%), hyperplasia (10-15%), carcinoma (2-3%) of cases. The most common presentation is asymptomatic hypercalcemia. Multiple pathological fractures, nephrocalcinosis as a presenting feature of primary hyperparathyroidism due to parathyroid adenoma is extremely rare at the age of 19 years. A case of parathyroid adenoma with multiple fractures of left femur, renal calculi, nephrocalcinosis, weight loss, constipation, dyspepsia abdominal pain was presented. The case was investigated completely with biochemical investigations, X-ray of forearm bones and femur, ultrasonography of neck and abdomen, CT scan of neck and abdomen, MRI scan, Scintigraphy of the neck. Right inferior parathyroid adenoma was diagnosed and confirmed by histopathological examination after excision. The post operative serum calcium levels became normal.