Opioid-Free Thyroid and Parathyroid Operations: Are Patients Satisfied With Pain Control?

BACKGROUND: The aim of this study was to evaluate pain control and patient satisfaction using an opioid-free analgesic regimen following thyroid and parathyroid operations. METHODS: Surveys were distributed to all postoperative patients following total thyroidectomy, thyroid lobectomy, and parathyroidectomy between January and April 2020. After surgery, patients were discharged without opioids except in rare cases based on patient needs and surgeon judgment. We measured patient-reported Numeric Rating Scale (NRS) pain scores and satisfaction categorically as either satisfied or dissatisfied. RESULTS: We received 90 of 198 surveys distributed, for a 45.5% response rate. After excluding neck dissections (n = 6) and preoperative opioid use (n = 4), the final cohort included 80 patients after total thyroidectomy (26.3%), thyroid lobectomy (41.3%), and parathyroidectomy (32.5%).The majority reported satisfaction with pain control (87.5%) and the entire surgical experience (95%). A similar proportion of patients reported satisfaction with pain control after total thyroidectomy (90.9%), thyroid lobectomy (90.5%), and parathyroidectomy (80.8%), indicating the procedure did not significantly impact satisfaction with pain control (P = .47). Patients who reported dissatisfaction with pain control were more likely to receive opioid prescriptions (30% vs 2.9%, P < .01), but the majority still reported satisfaction with their entire operative experience (70%). DISCUSSION: Even with an opioid-free postoperative pain regimen, most patients report satisfaction with pain control after thyroid and parathyroid operations, and those who were dissatisfied with their pain control generally reported satisfaction with their overall surgical experience. Therefore, an opioid-free postoperative pain control regimen is well tolerated and unlikely to decrease overall patient satisfaction.

A multi-institutional study evaluating and describing atypical parathyroid tumors discovered after parathyroidectomy.

Objective: To describe common intraoperative and pathologic findings of atypical parathyroid tumors (APTs) and evaluate clinical outcomes in patients undergoing parathyroidectomy. Methods: In this multi-institutional retrospective case series, data were collected from patients who underwent parathyroidectomy from 2000 to 2018 from three tertiary care institutions. APTs were defined according to the AJCC eighth edition guidelines and retrospective chart review was performed to evaluate the incidence of recurrent laryngeal nerve injury, recurrence of disease, and disease-specific mortality. Results: Twenty-eight patients were identified with a histopathologic diagnosis of atypical tumor. Mean age was 56 years (range, 23-83) and 68% (19/28) were female. All patients had an initial diagnosis of primary hyperparathyroidism with 21% (6/28) exhibiting clinical loss of bone density and 32% (9/28) presenting with nephrolithiasis or renal dysfunction. Intraoperatively, 29% (8/28) required thyroid lobectomy, 29% (8/28) had gross adherence to adjacent structures and 46% (13/28) had RLN adherence. The most common pathologic finding was fibrosis 46% (13/28). Postoperative complications include RLN paresis/paralysis in 14% (4/28) and hungry bone syndrome in 7% (2/28). No patients with a diagnosis of atypical tumor developed recurrent disease, however there was one patient that had persistent disease and hypercalcemia that is being observed. There were 96% (27/28) patients alive at last follow-up, with one death unrelated to disease. Conclusion: Despite the new AJCC categorization of atypical tumors staged as Tis, we observed no recurrence of disease after resection and no disease-specific mortality. However, patients with atypical tumors may be at increased risk for recurrent laryngeal nerve injury and incomplete resection.

A Unidirectional 96-Well Fluidic Culture Platform for Upstream Cell Dosing with Subsequent Downstream Nonlinear and Ascending Exposure Gradients for Real-Time and Cell-Based Toxicity Screening Environments.

Introduction: Because of the importance to create in vitro screening tools that better mimic in vivo models, for exposure responses to drugs or toxicants, reproducible and adaptable culture platforms must evolve as approaches to replicate functions that are native to human organ systems. The Stairstep Waterfall (SsWaterfall) Fluidic Culture System is a unidirectional, multiwell, gravity-driven, cell culture system with micro-channels connecting 12 wells in each row (8-row replicates). Materials and Methods: The construct allows for the one-way flow of medium, parent and metabolite compounds, and the cellular signaling between connected culture wells while simultaneously operating as a cascading flow and discretized nonlinear dosing device. Initial cell seeding in SsWaterfall mimics traditional static plate protocols but thereafter functions with controlled flow and ramping concentration versus time exposure environments. Results: To investigate the utility of a microfluidic system for predicting drug efficacy and toxicity, we first delineate device design, fabrication, and characterization of a disposable dosing and gradient-exposure platform. We start with detailed characterizations by demarcating various features of the device, including low nonspecific binding, wettability, biocompatibility with multiple cell types, intra-well and inter-well flow, and efficient auto-mixing properties of dose compounds added into the platform. Discussion: We demonstrate the device utility using an example in sequential testing-screening drug toxicity and efficacy across wide-ranging inducible exposures, 0 → IC100, featuring real-time assessments. Conclusion: The integrated auto-gradient technology, gravity flow with stairstep pathways, offers end-users an easy and quick alternative to evaluate broad-ranging toxicity of new compound entities (e.g., pharmaceutical, environmental, agricultural, cosmetic) as opposed to traditional/arduous manual drug dilutions and/or expensive robotic technology.

Parathyroidectomy for Tertiary Hyperparathyroidism: A Multi-Institutional Analysis of Outcomes.

BACKGROUND: Patients with tertiary hyperparathyroidism (HPT) often experience delays between diagnosis and referral for surgical treatment. We hypothesized that patients with tertiary HPT experience similarly high cure rates and low complication rates after parathyroidectomy compared with patients with primary HPT. METHODS: We retrospectively identified patients undergoing parathyroidectomy from the Collaborative Endocrine Surgery Quality Improvement Program for primary or tertiary HPT from January 2014 to April 2019. Patients were categorized according to their primary diagnosis and compared for cure rates and surgical complications. RESULTS: The study included 9030 patients, with 334 (3.7%) being treated for tertiary HPT. Parathyroidectomy provided a high cure rate (93.7%) in patients with tertiary HPT. However, adjusting for age, sex, and prior thyroid or parathyroid surgery, tertiary HPT was associated with a greater chance of persistent disease than was primary HPT (odds ratio: 2.3, 95% confidence interval: 1.3-4.0). Overall, complications were low for patients across both groups. However, patients with tertiary HPT were more likely to present to the emergency department (7.5% versus 3.3%; P < 0.001), be readmitted (5.1% versus 1.1%; P < 0.001), and develop a hematoma (1.5% versus 0.2%; P = 0.002). Both groups of patients shared similarly low rates of other complications, including mortality, vocal cord dysfunction, and surgical site infections (P < 0.5% for all). CONCLUSIONS: Patients undergoing parathyroidectomy for tertiary HPT experience high cure rates and low complication rates. However, tertiary HPT is associated with a greater chance of persistent disease and select complications. Nevertheless, the low rates of persistent disease and complications should not deter early referral for the treatment of tertiary HPT.

Implementation of Opioid-Free Thyroid and Parathyroid Procedures: A Single Center Experience.

BACKGROUND: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations. MATERIALS AND METHODS: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription. RESULTS: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001). CONCLUSIONS: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.

Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient.

Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX.

Variation in the Quality of Thyroid Nodule Evaluations Before Surgical Referral.

BACKGROUND: Thyroid nodules are highly prevalent, and owing to their malignant potential, proper evaluation is imperative. The objective of this study was to characterize variation in thyroid nodule evaluations. MATERIALS AND METHODS: This retrospective review included all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We determined the proportion of evaluations that contained a thyroid-stimulating hormone (TSH) level and a high-quality ultrasound because these components of thyroid nodule evaluations are common to several evidence-based guidelines. RESULTS: The study cohort included 64 patients, with a median age of 51.5 y. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). In total, 35.9% of evaluations did not include a TSH value, which is vital to any thyroid nodule evaluation. Most evaluations (95.3%) included a dedicated ultrasound, but only 12.3% of ultrasound reports commented on nodule size in three dimensions, structure, echogenicity, and lymph nodes, which we considered the minimum commentary indicative of a high-quality ultrasound. Only 51.5% of evaluations included both a TSH and a thyroid ultrasound. If patients receiving low-quality ultrasound reports were excluded, 9.4% of the entire cohort received a guideline-concordant, high-quality evaluation. CONCLUSIONS: Great variation exists in the quality of thyroid nodule evaluations before surgical referral. Two necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines are obtaining a TSH value and obtaining an ultrasound with enough information to risk stratify the nodule.

Improving quality measure maintenance: navigating the complexities of evolving evidence.

To be effective, healthcare quality measures must communicate clear, evidence-based standards to promote improved quality of care and outcomes. When the evidentiary foundation for measures changes, revisions must be made quickly and communicated clearly; otherwise, measures can confuse providers who are trying to reconcile the evidence-based care they deliver with outdated measure specifications. Outdated measures can also affect clinical decision making, potentially harming patients if the measures promote care that is not the best treatment for their condition according to the most recent evidence. This case study focuses on 2 measures for which the evidence base changed, yet implementation of revised specifications lagged and subsequently affected the payment programs in which the measures are used. The case study is shared to motivate collaboration among quality measurement stakeholders to advance shared responsibility for timely measure updates when evidence changes and to avoid confusion in measure implementation. Multiple parties share the responsibility for ensuring that measures are updated and aligned with evidence and practice recommendations. Issues of coordination among clinical experts, measure developers or stewards, and program implementers, including health plans, are not unique to any steward or implementer. The timing of new evidence releases and guidelines for the condition, service, or product being measured will always vary regardless of the measure update cycle for any one program. Changes to measure maintenance processes cannot totally negate these underlying challenges but can mitigate their impact. This case study calls for a national conversation to address opportunities for measure update process improvements.

Risk of Recurrence in Differentiated Thyroid Cancer: A Population-Based Comparison of the 7th and 8th Editions of the American Joint Committee on Cancer Staging Systems.

BACKGROUND: Differentiated thyroid cancer (DTC) survival is excellent, making recurrence a more clinically relevant prognosticator. We hypothesized that the new American Joint Committee on Cancer (AJCC) 8th edition improves on the utility of the 7th edition in predicting the risk of recurrence in DTC. METHODS: A population-based retrospective review compared the risk of recurrence in patients with DTC according to the AJCC 7th and 8th editions using the Surveillance, Epidemiology, and End Results-based Kentucky Cancer Registry from 2004 to 2012. RESULTS: A total of 3248 patients with DTC were considered disease-free after treatment. Twenty percent of patients were downstaged from the 7th edition to the 8th edition. Most patients had stage I disease (80% in the 7th edition and 94% in the 8th edition). A total of 110 (3%) patients recurred after a median of 27 months. The risk of recurrence was significantly associated with stage for both editions (p < 0.001). In the 7th edition, there was poor differentiation between lower stages and better differentiation between higher stages (stage II hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.39-2.11; stage III HR 3.72, 95% CI 2.29-6.07; stage IV HR 11.66, 95% CI 7.10-19.15; all compared with stage I). The 8th edition better differentiated lower stages (stage II HR 4.06, 95% CI 2.38-6.93; stage III HR 13.07, 95% CI 5.30-32.22; stage IV 11.88, 95% CI 3.76-37.59; all compared with stage I). CONCLUSIONS: The AJCC 8th edition better differentiates the risk of DTC recurrence for early stages of disease compared with the 7th edition. However, limitations remain, emphasizing the importance of adjunctive strategies to estimate the risk of recurrence.

Value of Intraoperative Parathyroid Hormone Assay during Parathyroidectomy in Dialysis and Renal Transplant Patients with Secondary and Tertiary Hyperparathyroidism.

BACKGROUND: In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. METHODS: The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. RESULTS: In the dialysis group, the median (25th-75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938-2,176), 143 pg/mL (78-244) and 112 pg/mL (59-153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180-403), 42 pg/mL (25-72), and 34 pg/mL (23-45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2-1.7) and estimated glomerular filtration rate of 55 mL/min (40-60). The median time between renal transplant and PTX surgeries was 22 months (7-81). The last median follow-up PTH level was 66 pg/mL (15-201) in the dialysis group and 54 pg/mL (17-72) in the transplant group (p = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (p = 0.6 and p = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. CONCLUSIONS: The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.

The Resilience of Life to Astrophysical Events.

Much attention has been given in the literature to the effects of astrophysical events on human and land-based life. However, little has been discussed on the resilience of life itself. Here we instead explore the statistics of events that completely sterilise an Earth-like planet with planet radii in the range 0.5-1.5R ⊕ and temperatures of ∼300 K, eradicating all forms of life. We consider the relative likelihood of complete global sterilisation events from three astrophysical sources - supernovae, gamma-ray bursts, large asteroid impacts, and passing-by stars. To assess such probabilities we consider what cataclysmic event could lead to the annihilation of not just human life, but also extremophiles, through the boiling of all water in Earth's oceans. Surprisingly we find that although human life is somewhat fragile to nearby events, the resilience of Ecdysozoa such as Milnesium tardigradum renders global sterilisation an unlikely event.

Necrotizing Fasciitis of the Breast Requiring Emergent Radical Mastectomy.

Necrotizing fasciitis is a rare, aggressive, soft-tissue infection that results in necrosis of skin, subcutaneous tissue, and fascia. It spreads rapidly and may progress to sepsis, multi-organ failure, and death. Predisposing conditions include diabetes, chronic alcoholism, advanced age, vascular disease, and immunosuppression and many cases are preceded by an injury or invasive procedure. Necrotizing soft-tissue infection of the breast is uncommon, with only a few reported cases in the literature. We present a 53-year-old diabetic woman who presented to the emergency room with several weeks of worsening breast and shoulder pain, swelling, and erythema. Upon formal evaluation by the surgical service, a necrotizing soft-tissue infection was suspected, and the patient was scheduled for emergent, surgical debridement. Because of the aggressive nature and high mortality of this disease, immediate surgical intervention, coupled with antibiotic therapy and physiologic support, is necessary to prevent complications and death.

Cystic multiglandular maternal hyperparathyroidism diagnosed by neonatal hypocalcemic seizures.

A 7-day-old male infant born to a healthy 33-year-old female at 37 weeks of gestation was brought to the local emergency department (ED) with sudden-onset tonic-clonic seizures. Laboratory testing revealed extreme hypocalcemia (ionized calcium of 3.2 mg/dl) and undetectable parathyroid hormone (PTH <10 pg/ml). Concomitant evaluation of the mother revealed both elevated ionized calcium (5.9 mg/dl) and PTH (116 pg/ml). The mother underwent preoperative ultrasound localization and sestamibi scan, followed promptly by parathyroidectomy. Given the cystic appearance and presence of multiglandular disease, evaluation for familial cystic parathyroid adenomatosis (hyperparathyroidism-jaw bone-tumor syndrome) and MEN 1 were undertaken. The infant was stabilized and discharged home. He returned to the ED with seizures at 1 month of age. After increasing calcium supplementation appropriately, he was monitored with weekly office visits. This represents a unique case of undiagnosed maternal primary hyperparathyroidism manifesting with intrauterine parathyroid suppression and hypocalcemic seizures in the newborn.

Improving the implementation of NICE public health workplace guidance: an evaluation of the effectiveness of action-planning workshops in NHS trusts in England.

RATIONALE, AIMS AND OBJECTIVES: There is evidence that health and well-being of the National Health Service (NHS) workforce affects organizational and patient outcomes. A Cochrane review of the effectiveness of clinical audit to improve quality of care has shown great variation between studies, depending on the design and intensity of support offered. This study evaluates the effectiveness of an organizational audit methodology with (1) action-planning workshops and follow-up and (2) audit feedback alone, to support the implementation of the National Institute for Health and Care Excellence (NICE) workplace guidance. METHODS: Two rounds of audit using a self-administered online questionnaire were conducted. An overall implementation score was devised for each trust. Following round 1, interviews were conducted with a cohort of trusts with high scores. The interviews used a theory-based framework to identify predictors of and barriers to successful implementation. From this, the content for action-planning workshops was devised and workshops held with lower scoring trusts. The remaining trusts received only written feedback on their audit results. Changes in the implementation score between rounds 1 and 2 were compared within and between cohorts. RESULTS: The median improvement in scores between rounds 1 and 2 was statistically significant except where baseline score was high. The improvement for trusts who received workshops was very much better than those who did not (P < 0.001). This difference remained after adjustment using stratification by baseline score (P = 0.001). CONCLUSIONS: Audit, combined with action-planning workshops and follow-up, appears to be more effective in improving implementation of NICE workplace health and well-being guidance than audit with feedback alone.

Esophageal fistula complicating thyroid lobectomy.

Thyroidectomy is associated with low morbidity and mortality. Esophageal perforation following thyroidectomy has been reported only three times previously, with subsequent fistulization occurring in two of these cases. The authors present the first such case report in the English-speaking literature.

Preoperative laryngoscopy in thyroid surgery: Do patients' subjective voice complaints matter?

BACKGROUND: Although routine preoperative laryngoscopy has been standard practice for many thyroid surgeons, there is recent literature that supports selective laryngoscopy. We hypothesize that patients' preoperative voice complaints do not correlate well with abnormalities seen on preoperative laryngoscopy. METHODS: A retrospective chart review of a 3-year, single-surgeon experience was performed. Records of patients undergoing thyroid surgery were reviewed for patient voice complaints, prior neck surgery, surgeon-documented voice quality, and results of laryngoscopy. RESULTS: Of 464 patients, 6% had abnormal laryngoscopy findings, including 11 cord paralyses (2%). Preoperatively, 39% of patients had voice complaints, but only 10% had a corresponding abnormality on laryngoscopy. Only 4% of patients had a surgeon-documented voice abnormality with 72% corresponding abnormalities on laryngoscopy, including 8 cord paralyses. When eliminating patient voice complaints and using only history of prior neck surgery and surgeon-documented voice abnormality as criteria for preoperative laryngoscopy, only 1 cord paralysis is missed and sensitivity (91%) and specificity (86%) were high. Also, when compared with routine laryngoscopy, 84% fewer laryngoscopies are performed. CONCLUSION: When using patients' voice complaints as criteria for preoperative laryngoscopy, the yield is low. We recommend using surgeon-documented voice abnormalities and history of prior neck surgery as criteria for preoperative laryngoscopy.

An optical relay approach to very low cost hybrid polymer-complementary metal-oxide semiconductor electrophoresis instrumentation.

Electrophoresis is an integral part of many molecular diagnostics protocols and an inexpensive implementation would greatly facilitate point-of-care (POC) applications. However, the high instrumentation cost presents a substantial barrier, much of it associated with fluorescence detection. The cost of such systems could be substantially reduced by placing the fluidic channel and photodiode directly above the detector in order to collect a larger portion of the fluorescent light. In future, this could be achieved through the integration and monolithic fabrication of photoresist microchannels on complementary metal-oxide semiconductor microelectronics (CMOS). However, the development of such a device is expensive due to high non-recurring engineering costs. To facilitate that development, we present a system that utilises an optical relay to integrate low-cost polymeric microfluidics with a CMOS chip that provides a photodiode, analog-digital conversion and a standard serial communication interface. This system embodies an intermediate level of microelectronic integration, and significantly decreases development costs. With a limit of detection of 1.3±0.4nM of fluorescently end-labeled deoxyribonucleic acid (DNA), it is suitable for diagnostic applications.

Surgeon-driven thyroid interrogation of patients presenting with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (pHPT) is an increasingly prevalent disease affecting all age groups. The authors sought to determine the impact of a "thyroid interrogation" practice protocol on the surgical treatment of patients with the diagnosis of pHPT referred to a single surgeon. STUDY DESIGN: We performed a retrospective review of prospectively gathered data on parathyroidectomy (PTX) patients undergoing both a prospective clinical thyroid evaluation and thyroid ultrasound between January 2008 and October 2012. RESULTS: Only 5.6% of 468 PTX patients were referred to a single surgeon for both parathyroid and thyroid surgical evaluation; 31% of patients had known pre-existing thyroid disease (hypothyroidism most commonly), and 22% of patients had palpable thyroid abnormalities unrecognized in 67% of cases by the referring physician. Of the 468 patients, 2.6% had a history of classic head and neck radiation exposure, 2.6% a history of radio-iodine treatment, and 3% a family history of thyroid cancer. Thyroid abnormalities were found on ultrasound in 61% of patients, and 26% of patients underwent thyroid biopsies. Parathyroid and thyroid surgery was combined for 18.4% of patients; indications included obstructive symptoms (3.2%), hyperthyroidism (0.9%), intraoperative findings (5.1%), and concern for malignancy (9.2%). Malignancy was diagnosed in 23 patients (4.9%), only 8 of whom had been referred for thyroid evaluation. CONCLUSIONS: The majority of patients referred for PTX had evidence of thyroid pathology. For an important minority of these patients, benign and malignant disease was identified that merited surgical treatment at the time of PTX. We recommend comprehensive thyroid evaluation of patients referred for PTX.

Intrapericardial parathyroid adenoma†.

Primary hyperparathyroidism from a parathyroid adenoma is common. Ectopic parathyroid glands have been reported in numerous locations, including the chest. We present a single case report of an intrapericardial parathyroid gland found after failed bilateral neck exploration. The patient presented with severe, recurrent nephrolithiasis and acute renal failure prior to his surgical intervention. Repeat imaging identified a parathyroid adenoma in the mediastinum that was localized to the aortopulmonary window. After attempts at minimally invasive thoracotomy and posterolateral thoracotomy, a median sternotomy was ultimately required to identify the adenoma.