Ectopic parathyroid adenoma in the pyriform sinus.

BACKGROUND: Ectopic parathyroid glands may complicate the surgical approach to primary hyperparathyroidism. We describe a rare ectopic parathyroid location, the pyriform sinus. METHODS: Three patients, 2 after prior unsuccessful parathyroid exploration, were found to have ectopic parathyroid adenomas in the pyriform sinus. Two cases were identified by 4D-CT of the neck. The other was localized by a technetium 99m sestamibi single photon emission CT (SPECT). In each case, office endoscopy confirmed the lesions. The patients were treated by either transoral laser or robotic resection of the parathyroid adenoma. RESULTS: After surgery, the patients had resolution of their hyperparathyroidism. CONCLUSION: Ectopic parathyroid adenomas in the pyriform sinus are rare, but should be considered in those patients who have had a failed neck exploration and in those who undergo 4D-CT scanning or SPECT scanning.

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus Immunology: A Pilot Study.

OBJECTIVE: To elucidate specific cytokine and chemokine markers in patients diagnosed with pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). STUDY DESIGN: Prospective cohort study. STUDY SETTING: Academic university hospital. METHODS: Tonsil tissue was collected from 24 patients and organized into 3 groups: experimental PANDAS cohort (12 patients), group A beta hemolytic streptococcus control cohort (6 patients), and obstructive sleep apnea control cohort (6 patients). Each tissue sample was extracted with MSD Tris lysis buffer, and protein lysates were analyzed for human chemokines and cytokines by the Human Cytokine 30-Plex Assay on the Mesoscale System. RESULTS: We identified a significant difference in expression regarding the 8 following cytokines when comparing the experimental PANDAS, group A beta hemolytic streptococcus, and obstructive sleep apnea control cohorts: tumor necrosis factor-α and eotaxin-3. In addition, our group also identified a significant reduction in the expression of interleukin (IL)-8, interferon inducible protein-10, IL-17a, interferon-γ, IL-10, and IL-12 across the aforementioned groups. CONCLUSIONS: Patients diagnosed with PANDAS appear to maintain significantly different concentrations of cytokines when compared with patients afflicted by chronic group A beta hemolytic streptococcus infections and obstructive sleep apnea. As a result, one could potentially use the described characterization of immunologic markers as a basis for future mechanistic and epidemiological studies.

Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture?

BACKGROUND: Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database. METHODS: A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury. RESULTS: Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers. CONCLUSIONS: Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.

Upper extremity bypass for chronic ischemia--a national surgical quality improvement program study database study.

OBJECTIVE: We undertook this study to determine the outcomes of upper extremity arterial reconstruction for chronic ischemia. METHODS: The National Surgical Quality Improvement Program Database was queried to identify all patients who had undergone an upper extremity bypass for chronic ischemia between 2005 and 2007. RESULTS: A total of 55 patients were identified in a primarily female population (71% women). Mean age was 57. The most common preoperative diagnoses included ischemia resulting from prior arterial thromboembolism in 16 (29%) patients and atherosclerotic upper extremity arterial disease in 11 (20%) patients. The most common procedures performed included axillo-brachial bypass in 17 (31%) patients, brachial-brachial bypass in 11 (20%) patients, and carotid-brachial bypass in 11 (20%) patients. There were no perioperative deaths and no acute graft failures. CONCLUSION: Although upper extremity bypass remains rare, the procedures appear to be safe with excellent 30-day results. Indications differ from those for lower extremity bypass.