The anti-proliferative effects of a frankincense extract in a window of opportunity phase ia clinical trial for patients with breast cancer.

PURPOSE: Boswellic acids, active components of frankincense, suppress tumor proliferation in vitro with a strong clinical trial safety profile in patients with inflammatory diseases. We performed a Phase Ia window of opportunity trial of Boswellia serrata (B. serrata) in patients with breast cancer to evaluate its biologic activity and safety. METHODS: Patients with invasive breast cancer were treated pre-operatively with B. Serrata (2400 mg/day PO) until the night before surgery for a median of 11 days (SD 6 days; range: 5-23 days). Paraffin-embedded sections from pretreatment diagnostic core biopsies and post-treatment surgical excisions were evaluated using a tunnel assay and immunohistochemistry staining with Ki-67 antibodies. A non-intervention retrospective control arm consisting of core and surgical tissue specimens from untreated patients was used to compare patients treated with B. Serrata. The change in proliferation and apoptosis between diagnostic core specimens and surgical specimens was compared between the control and treatment groups using a two-tailed paired t-test. RESULTS: Twenty-two patients were enrolled, of which 20 received treatment, and 18 had sufficient tissue for IHC. There was an increase in percent change in proliferation from core biopsy to surgical excision in the control group (n = 18) of 54.6 ± 21.4%. In the B. serrata-treated group there was a reduction in proliferation between core biopsy and excision (n = 18) of 13.8 ± 11.7%. This difference was statistically significant between the control and B. serrata-treated groups (p = 0.008). There was no difference in change in apoptosis. There were no serious adverse events related to the drug. CONCLUSION: Boswellia serrata inhibited breast cancer proliferation and was well-tolerated in a Phase Ia window of opportunity trial.

The impact of nurse navigation on timeliness to treatment for benign high-risk breast pathology.

PURPOSE: High-risk breast pathology is a breast cancer risk factor for which timely treatment is crucial. Nurse navigation programs have been implemented to minimize delays in patient care. This study evaluated nurse navigation in terms of timeliness to surgery for patients with high-risk breast pathology. METHODS: This was a single-institution, retrospective review of patients with identified high-risk breast pathology undergoing lumpectomy between January 2017 and June 2019. Patients were stratified into cohorts based on periods with and without nurse navigation. Preoperative and postoperative time to care as well as demographic and tumor characteristics were compared using univariate and multivariate analysis. RESULTS: 100 patients had assigned nurse navigators and 29 patients did not. Nurse navigation was associated with reduced time from referral to date of surgery (DOS) by 16.9 days (p = 0.003). Patients > 75 years had a shorter time to first appointment (p = 0.03), and patients with Medicare insurance had a reduced time from referral to DOS (p = 0.005). 20% of all patients were upstaged to cancer on final surgical pathology. CONCLUSION: Nurse navigation was significantly associated with decreased time to care for patients with high-risk breast pathology undergoing lumpectomy. We recommend nurse navigation programs as part of a comprehensive approach for patients with high-risk breast pathology.

Opioid Use Patterns in a Statewide Adult Medicaid Population Undergoing Elective Lumbar Spine Surgery.

STUDY DESIGN: Retrospective administrative database review. OBJECTIVE: Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. SUMMARY OF BACKGROUND DATA: Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. MATERIALS AND METHODS: Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). RESULTS: A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). CONCLUSIONS: Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

Surgical prescription opioid trajectories among state Medicaid enrollees.

OBJECTIVE: The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN: Retrospective cohort. SETTING: Administrative claims data. PATIENTS AND PARTICIPANTS: Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS: More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS: Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

Incidence and patterns of persistent opioid use in children following appendectomy.

BACKGROUND: The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN: A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS: 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION: Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE: III.

New chronic opioid use in Medicaid patients following cholecystectomy.

Background: Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods: Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results: A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion: Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.

Surgical Outcomes Improvement and Health Inequity in a Regional Quality Collaborative.

BACKGROUND: Surgical quality improvement initiatives may impact sociodemographic groups differentially. The objective of this analysis was to assess the trajectory of surgical morbidity by race and age over time within a Regional Collaborative Quality Initiative. STUDY DESIGN: Adults undergoing eligible general surgery procedures in South Carolina Surgical Quality Collaborative hospitals were analyzed for the presence of at least 1 of 22 morbidities between August 2015 and February 2020. Surgery-level multivariable logistic regression assessed the racial differences in morbidity over time, stratified by age group (18 to 64 years, 65 years and older), and adjusting for potential patient- and surgical-level confounders. RESULTS: A total of 30,761 general surgery cases were analyzed, of which 28.4% were performed in Black patients. Mean morbidity rates were higher for Black patients than non-Black patients (8.5% vs 6.0%, p < 0.0001). After controlling for race and other confounders, a significant decrease in monthly mean morbidity through time was observed in each age group (odds ratio [95% CI]: age 18 to 64 years, 0.986 [0.981 to 0.990]; age 65 years and older, 0.991 [0.986 to 0.995]). Comparing morbidity rates from the first 4 months of the collaborative to the last 4 months reveals older Black patients had an absolute decrease in morbidity of 6.2% compared with 3.6% for older non-Black patients. Younger Black patients had an absolute decrease in morbidity of 4.7% compared with a 3.0% decrease for younger non-Black patients. CONCLUSIONS: Black patients had higher morbidity rates than non-Black patients even when controlling for confounders. The reasons for these disparities are not apparent. Morbidity improved over time in all patients with older Black patients seeing a larger absolute decrease in morbidity.

Prognostic factors for residual occult disease in shave margins during partial mastectomy.

PURPOSE: Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins. METHODS: Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors. RESULTS: 166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28 months (9-50 months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS. CONCLUSION: Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.

Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017.

OBJECTIVES: Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS: Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS: There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS: Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.

Facilitated Regional Collaboration and In-Hospital Surgical Complication.

BACKGROUND: Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina. STUDY DESIGN: In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics. RESULTS: The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative. CONCLUSIONS: Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative.

A Multifaceted Approach to Opioid Education, Prescribing, and Disposal for Patients with Breast Cancer Undergoing Surgery.

BACKGROUND: Standardized prescribing practices are recommended to decrease opioid abuse, however, data regarding the handling and disposal of leftover narcotics are lacking. This quality improvement project and analysis evaluated implementation of standardized prescribing, opioid education, and a narcotic disposal system. METHODS: This initiative was implemented over a 1-y period among patients who underwent breast surgery. The project included the following: 1) implementation of standardized prescribing, 2) voluntary and anonymous survey analysis, and 3) preoperative education regarding risks of opioids, charcoal disposal bag distribution, and follow-up survey to assess use and use of intervention. RESULTS: Preintervention surveys were completed by 53 patients, and 60% (n = 32) underwent lumpectomy. Narcotic prescriptions were filled by 90%; median number of pills taken was 3 (range 0-24), however 93% felt that a non-narcotic was more effective. Eighty three percentage of patients had unused pills, and 58% kept these pills in an unlocked cabinet. Postintervention surveys were completed by 66 patients, and 48% (n = 32) underwent lumpectomy. Narcotic prescriptions were filled by 88%, median number of pills taken was 4 (range 0-40), and 89% of patients had pills leftover. Sixty seven percentage of patients found the education handout useful and charcoal bag use was reported by 37% (n = 17). The median postoperative pain control satisfaction score was 4.5 (5-point Likert scale, 1 = very dissatisfied, 5 = very satisfied) on both preintervention and postintervention surveys. CONCLUSIONS: This study, which included standardized prescribing parameters, opioid education, and implementation of a disposal method, was found to be feasible, beneficial, and did not compromise postoperative pain control.

Specialty-specific reduction in opioid prescribing after common pediatric surgical operations.

BACKGROUND: Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair. METHODS: Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic. RESULTS: Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention. CONCLUSIONS: The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber. TYPE OF STUDY: retrospective comparative chart review. LEVEL OF EVIDENCE: IV.

South Carolina Surgical Quality Collaborative Colon Surgery Outcomes Vary by Age and Race.

Identifying disparities in surgical outcomes among patient populations may help hospitals target patients at highest risk for complications. The South Carolina Surgical Quality Collaborative (SCSQC) is a regional collaborative made up of eight facilities whose goal is to improve the quality and value of general surgical care in South Carolina. Using SCSQC data, we reviewed colon surgery outcomes to determine whether disparities exist between specific patient populations. SCSQC colon surgery data were reviewed from August 2015 to August 2017. SSI, length of stay, return to the ED, and reoperation rates were used as outcome measures. They were evaluated in patient populations stratified by gender, race (white, black, and other), and age (<50, 50-70, and >70 years). A total of 2611 patients were included in this study. Statistically significant differences in outcomes were identified between white and black patients in length of stay (6.0 vs 7.5 days, P < 0.0001) and return to the ED (8.1% vs 14.7%, P < 0.0001), but not in SSI (6.4% vs 6.8%, P = 0.8839) or reoperation rates (6.4% vs 8.4%, P = 0.1886). Length of stay increased with increasing age (4.1 vs 7.1 vs 8.8, P < 0.0001). SSI varied by age (4.0% vs 8.2% vs 6.4%, P = 0.0005), as did return to the ED (11.2% vs 9.7% vs 769%, P = 0.0987) and reoperation rates (4.5% vs 8.1% vs 8.2%, P = 0.0034). SCSQC data indicate that race and age may place patients at risk for negative outcomes after colorectal surgery.

The South Carolina Surgical Quality Collaborative: A New Effort to Improve Surgical Outcomes in South Carolina.

Regional surgical quality Collaboratives are improving surgical quality and cutting costs by building regional relationships that leverage information sharing to improve outcomes. The South Carolina Surgical Quality Collaborative (SCSQC) is a new regional surgical quality Collaborative focused on improving general surgery outcomes in South Carolina. It is a joint effort which brings together the skills and resources of Health Sciences South Carolina, the South Carolina Hospital Association, and the Blue Cross Blue Shield of SC Foundation to create a web-based data collection system to provide real-time outcomes data to participating surgeons, and establishing a supportive network for sharing best practices and promoting data driven quality improvement. Members of the SCSQC abstracted more than 8000 general surgery cases from eight participating hospitals in its first year. These facilities are spread across the state of South Carolina and range from large academic referral centers to small community hospitals. The resulting data should be representative of much of the surgical care provided in South Carolina. Monthly conference calls and quarterly face-to-face meetings occur with site Surgeon Leads, site Surgical Clinical Quality Reviewer, and Collaborative leaders. Each site is pursuing a quality improvement project addressing issues identified from analysis of their initial data. Early results on these efforts are encouraging. The SCSQC is a new regional surgical quality Collaborative, which leverages multiple state resources, builds on the successes of similar Collaboratives in Michigan and Tennessee, with the goal to improve the quality and value of general surgical care for South Carolinians.

Trends in bariatric surgery, 2002-2012: do changes parallel the obesity trend?

BACKGROUND: It is well documented that bariatric surgery is an effective weight loss intervention, and bariatric procedure rates have increased over time. However, there was a period of plateau in procedure rates in the mid to late 2000s. Recent literature has not identified current trends in procedure rates or associations between bariatric surgery and population factors, such as obesity and diabetes. OBJECTIVES: The purpose of this study was to determine trends in statewide rates of bariatric operations, obesity, and diabetes over an 11-year period and to determine if population factors are associated with procedure rates. SETTING: Data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) were utilized to identify a study sample population of patients who underwent bariatric procedures from 2002-2012. METHODS: State level population characteristics were obtained from the Behavioral Risk Factor Surveillance System and Census Bureau Data for the 11-year period. Statistical analyses determined rates of surgery, obesity, and diabetes over time, as well as associations between surgery rates and population factors. RESULTS: From 2002-2012, bariatric procedure rates increased, with an exponential rise in laparoscopic surgical methods. Procedure rates reached a peak value in 2009 and then plateaued. Statewide obesity and diabetes rates increased over time, although there was no association between these population factors and procedure rates. Women had consistently higher rates of bariatric operations. CONCLUSION: Although bariatric procedures are an evidenced-based effective treatment for obesity, procedure rates were not associated with the increasing obesity and diabetes rates in the United States. Further research is needed to identify factors that affect the adoption and diffusion of bariatric operations to increase diffusion of beneficial innovations and improve overall quality of care and health outcomes.

Percutaneous endoscopic gastrostomy complications in a tertiary-care center.

Since its introduction in 1980 the percutaneous endoscopic gastrostomy (PEG) has become the procedure of choice for establishing enteral access. However, there is still a relatively high complication rate associated with PEG placement. We reviewed the complications associated with PEG placement at our tertiary-care referral center. A retrospective chart review was conducted on patients over 17 years of age undergoing PEG placement between January 1, 1994 and March 1, 1996. Indications for surgery, antibiotic use, and postoperative complications were determined. There were 166 PEGs placed during this time and 27 (16.3%) complications. There was one death (0.6%) directly related to PEG placement. Thirteen patients (7.8%) died within 30 days of PEG placement and an additional 12 patients (7.2%) died before leaving the hospital. Wound infections occurred in nine (5.4%) patients including one case of necrotizing fasciitis. Only four of 153 (2.6%) patients who received preoperative antibiotics developed wound infections, whereas five of 13 (38.5%) patients without antibiotic prophylaxis developed infections. We conclude that percutaneous endoscopic gastrostomy is a safe and effective way of establishing enteral access in most patients. A relatively high mortality rate can be expected as a result of underlying medical problems. Antibiotics should be given to help prevent local wound infections.

Spontaneous infarction of a parathyroid adenoma: two case reports and review of the literature.

The spontaneous infarction of a parathyroid adenoma is an uncommon event, although it has been previously described. Patients may present symptomatically or experience resolution of their hyperparathyroidism. As such the appropriate clinical management of these patients remains unclear. We present two cases of spontaneous infarction of parathyroid adenomas. The first presented with neck pain and dysphagia and experienced at least temporary resolution of her hyperparathyroidism. The second patient experienced a fall in his parathyroid hormone and calcium levels before neck exploration. Infarcted parathyroid adenoma was diagnosed on pathologic evaluation of the surgical specimen. Inflammation surrounding the infarcted adenoma provided for a technically difficult operation. Although resolution of hyperparathyroidism has been described postinfarction, a regeneration of the parathyroid adenoma may occur. Therefore neck exploration and parathyroidectomy should still be considered. We propose a period of observation after diagnosis of spontaneous parathyroid adenoma infarction to avoid these acute inflammatory changes that have been described.