The cost of screening for synchronous thyroid disease in patients presenting with primary hyperparathyroidism.

OBJECTIVE: To use decision analysis to compare the costs associated with minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE) in patients with primary hyperparathyroidism with regard to treatment of incidental synchronous thyroid disease. DESIGN: We developed a decision tree model to evaluate the cost of managing thyroid pathology in primary hyperparathyroidism with the following 3 approaches: MIP, MIP with preoperative ultrasonography, and routine BNE with intraoperative thyroid evaluation. We tested the robustness of the optimal decision with sensitivity analyses. SETTING: A tertiary care academic medical center. MAIN OUTCOME MEASURE: Total costs from a provider perspective. RESULTS: Minimally invasive parathyroidectomy without an active search for thyroid abnormalities was determined to have the lowest expected cost ($5275 per patient). Parathyroid surgery with routine preoperative thyroid ultrasonography and further thyroid treatment as indicated had an expected cost of $5910 per patient. Bilateral neck exploration with intraoperative thyroid evaluation and treatment of the thyroid gland had an expected cost of $5916 per patient. Sensitivity analyses confirmed the robustness of the results across a reasonable range of surgical and imaging costs. CONCLUSIONS: Minimally invasive parathyroidectomy is not contraindicated on the basis of cost by an inability to screen for synchronous thyroid disease. In addition, ultrasonographic screening of the thyroid glands of patients undergoing MIP is not cost prohibitive and, in fact, is less costly than BNE. Ultrasonography has the added advantage of confirming the location of the offending parathyroid.

The effect of single agent oral fusaric acid (FA) on the growth of subcutaneously xenografted SCC-1 cells in a nude mouse model.

OBJECTIVE: To determine whether oral administration of fusaric acid (FA) inhibits tumor growth in an animal model of head and neck cancer (HNSCC). DESIGN: In vivo murine model, two arm controlled study. METHODS: Thirty-eight (38) 5-week-old athymic nude mice were randomly assigned to a fusaric acid treatment group (1 mg/mL) (n = 19) or a sterile saline group (n = 19). A left, lateral flank subcutaneous injection of 2.0 x 10(6) UM-SCC-1 cells were administered to all mice on day 1. Both groups were gavaged daily with either 0.25 mLs of oral FA or sterile saline throughout the experiment (32 days). Latency to a measurable tumor (> or =65 mm3), and tumor volumes were recorded after tumor xenografting. Tumor weights were recorded at the conclusion of the experiment. Tumor volume growth curves were modeled as polynomial functions of time with treatment interaction effects. Survivorship functions for time to measurable tumor were estimated using the Kaplan-Meier product limit estimator. RESULTS: Survival analysis showed mice treated with FA developed measurable tumors after a significantly longer interval post-xenografting than control mice (p = 0.00451). By Day 9, all mice in the control group had developed measurable tumors in comparison to only 78% of mice in the FA group. Likewise, estimated growth curves for both groups suggested that mice receiving FA demonstrated significantly slower tumor growth rates throughout the entire study period (p < 0.0001). At the conclusion of the experiment, tumor weights from both the control and FA groups were also significantly different (p = 0.0142). CONCLUSIONS: Single agent oral fusaric acid (1 mg/mL) is an inhibitor of UM-SCC-1 in a murine model. As an orally active agent, it may have a potential role in the treatment of human squamous cell carcinoma of the head and neck.

Operative time analysis of miniplate fixation of the mandible.

Our purpose in this study was to report and compare operating room times for the various methods of mandible fracture repair. We describe a methodology of treatment in selected patients, using efficient repair techniques; namely, miniplate fixation with four-screw mandibular occlusion. We report our outcomes in successful healing, occlusion, complications, and operating times. A retrospective chart review was performed of 68 patients suffering mandible fractures treated by various surgeons at a single institution. Miniplate fixation technique requires significantly less time in the operating room than other mandible repair techniques, including mandibulomaxillary fixation. Miniplate fixation technique is both an efficacious and an efficient means of repairing certain mandible fractures.

Perioperative parathyroid hormone assay for diagnosis and management of postthyroidectomy hypocalcemia.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to assess the relationship between perioperative changes in parathyroid hormone (PTH) level and the likelihood of postthyroidectomy hypocalcemia. STUDY DESIGN: In a series of 78 patients undergoing total or completion thyroidectomy, PTH levels were measured before surgery and at 10 minutes after removal of the thyroid gland. METHODS: A prospective, nonrandomized collection of serum from 78 consecutive total or completion thyroidectomy procedures performed by a single surgeon was carried out over 18 months. Analysis is made of PTH levels, serum calcium values, need for calcium supplementation, and symptoms of hypocalcemia. RESULTS: Both a PTH change of 75% and an absolute postoperative PTH of 7 pg/mL are accurate standards for predicting symptomatic hypocalcemia after total or completion thyroid surgery. CONCLUSIONS: Perioperative PTH levels are a tool for the prediction of postoperative symptomatic hypocalcemia after thyroidectomy. A PTH level drawn 10 minutes after removal of the thyroid predicts the likelihood of postoperative hypocalcemia.

Synchronous thyroid pathology in patients presenting with primary hyperparathyroidism.

BACKGROUND: Thyroid and parathyroid pathology may coexist; classically, this is described in multiple endocrine neoplasia. Other nonsyndromic scenarios result in pathologies of these endocrine organs coexisting. This can create a challenge in the clinical decision making and management of these patients. It is optimal to deal with both problems in one operative procedure, if surgery is required. METHODS: A retrospective review of cases of synchronous thyroid and parathyroid pathology that were managed surgically over a 3-year period by a single endocrine surgeon at a single university medical center. RESULTS: Seventeen cases of synchronous thyroid and parathyroid disease were discovered. All required surgical management of thyroid and parathyroid conditions. Reasons included removal of thyroid goiter for access to an adenoma, worrisome thyroid lesions coexistent with a parathyroid adenoma, and an intrathyroid parathyroid adenoma. Cases of incidental discovery of a second endocrine condition while the first was evaluated will be reported. CONCLUSIONS: A head and neck endocrine surgeon needs to be aware of the possible coexistence of thyroid and parathyroid pathologies so that, when encountered, they can be safely and efficiently managed in a single procedure.

Parathyroid carcinoma.

Parathyroid carcinoma is a relatively rare tumor that is prone to recurrence and poor loco-regional control. This article discusses the epidemiology, presentation, operative findings, pathology,management, genetics, outcome, and other aspects of parathyroid carcinoma.

Calciphylaxis.

Calciphylaxis is a condition with a generally poor prognosis about which relatively little is known. Possible improvement in prognosis is noted if the diagnosis can be made early to avoid progression of soft tissue lesions and resulting complications. The mainstays of therapy are wound care and therapy aimed at controlling infection and the progression of disease. Parathyroidectomy seems to benefit some patients, but controversy remains as to the extent of overall patient benefit and scenarios for its appropriate use.