Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis.

Importance: Emerging computed tomographic (CT) imaging techniques for the localization of primary hyperparathyroidism (PHPT) may be superior to the current imaging standard, thus necessitating a critical review and pooling of available evidence. Objective: Primary hyperparathyroidism requires accurate imaging to guide definitive surgical management. Advanced techniques including 4-dimensional computed tomographic (4D-CT) scan have been investigated over the past decade. We sought to evaluate the efficacy of these emerging imaging techniques through pooled analysis of the existing evidence. Data Sources: PubMed, Embase, and Web of Science databases were queried for original English articles without any restrictions on date. Study Selection: We included comparative observational studies but excluded animal studies, case reports, and case series. Overall, 353 abstracts were screened independently by 2 investigators along with a third reviewer to resolve conflicts. A total of 26 full-text articles were included in this review. Data Extraction and Synthesis: This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data was independently extracted by 2 investigators and subsequently pooled into a meta-analysis using a random-effects model. Main Outcomes and Measures: Measures of imaging diagnostic performance such as sensitivity, specificity, positive predictive value, and negative predictive value were the primary outcomes of interest. Results: Overall, of 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Of the 26 studies included, there were 5845 patients, of which 4176 were women (79.2%). The average of mean ages reported in 23 studies was 60.9 years. Meta-analysis in all patients with PHPT revealed pooled sensitivity that was greater with 4D-CT (81%; 95% CI, 77%-84%; I2 = 88%) compared with the current first-line modality of sestamibi-single-photon emission CT (SPECT/CT) (65%; 95% CI, 59%-70%; I2 = 93%). For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I2 = 93%) in contrast to 53% (95% CI, 35%-71%; I2 = 81%) for sestamibi-SPECT/CT. The overall quality of the 26 studies was moderate with a median (range) Methodological Index for Nonrandomized Studies score for all included studies of 15.5 (13-19). Conclusions and Relevance: The findings of this systematic review and with meta-analyses of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed to determine the clinical significance of this improvement in localization.

Anterior cervical discectomy and fusion in the setting of kissing carotids: A technical report and literature review.

BACKGROUND: The "kissing carotids" (KCS) phenomenon refers to bilateral retropharyngeal displacement of the internal carotid arteries (ICA). This anomalous anatomy can impose a significant surgical challenge to spine surgeons. OBJECTIVE: In this report, we describe our approach for an anterior cervical discectomy and fusion in the setting of kissing carotids. METHODS: We discuss our case, surgical technique, rationale, and outcome. Additionally, we conducted a systematic review of the literature. CASE DESCRIPTION: An 82-year-old female presented to our service with progressive myelopathy. Cervical spinal imaging revealed a large disc herniation at C3-C4 and severe spinal canal stenosis. Vascular imaging showed anomalous ICAs bilaterally overlying the prevertebral fascia at the midline. The patient received aspirin preoperatively and underwent a multidisciplinary approach with neurosurgery and otolaryngology. A standard transcervical approach centered on the C5-C6 disc space, where the carotid arteries splayed most from midline, allowed for facilitated visualization and mobilization of the vessels. Prevertebral dissection was then performed rostrally to the C3-C4 disc space. The patient was put into burst suppression prior to retraction and underwent uncomplicated anterior discectomy and fusion. CONCLUSIONS: KCS is a rare but critical presentation of extreme medial displacement of bilateral ICAs. Few cases have been reported in the spinal surgery literature. Knowledge of this rare variant is important to avoid iatrogenic injury and complications.

Injuries to the azygous venous system.

BACKGROUND: Azygous venous system injuries are rare. Although not commonly classified as a thoracic great vessel, the azygous system manifests morbidity and mortality that is similar to that of other great vessel injuries. METHODS: Over a 40 year period, data were retrospectively collected and charts reviewed from a vascular injury database. RESULTS: A total of 22 injuries to the azygous venous system were identified with 21 to the azygous vein and 1 to the hemiazygous vein. All were secondary to penetrating trauma, with 19 from gunshot wounds and 3 from stab wounds. Eight of 22 patients died for an overall mortality of 36%. All patients had associated injuries, with concomitant injury to the lung noted in all cases. CONCLUSIONS: Injuries to the azygous venous system have a significant associated lethality. As an azygous venous injury is not typically the indication for operation, anterior incisions are often employed, making exposure difficult. In the majority of injured patients, the azygous system injury was found after excluding injuries to the heart, lung, and great vessels. A key finding in detecting these injuries through an anterior incision is continued hemorrhage of dark blood from a posterior location in the thoracic cavity. The azygous venous system should be considered early as a source of significant hemorrhage from the posterior mediastinum.

The role of government in health care: a societal issue.

The history of the role of government in health care is briefly reviewed and more fully discussed in the United States since the establishment of Medicare 40 years ago. Data and other evidence of the unintended consequences of this historic event are presented, identifying thorny and onerous issues that government has created, showing failed attempts at band-aid solutions, and suggesting that our present health care system is in disarray and cannot be rectified by the "incrementalism" approach. The establishment of a high-level commission jointly endorsed by the President of the United States and Congress is recommended to consider and analyze scrupulously all the components of our health care complex and provide a "roadmap" toward achieving a universal health care system that is culturally acceptable, affordable, and of optimal quality while avoiding its administration and total control by an ultimately rigid and unwieldy governmental or insurance-industry bureaucracy.

Use of the MicroMed DeBakey VAD for the treatment of end-stage heart failure.

Congestive heart failure poses a serious health risk to millions of Americans. Medical therapy for advanced stages of this condition has offered a minimal benefit and surgical treatment through transplantation is limited by the donor organ shortage. Although left ventricular assist devices may represent the future of therapy for this disease, the first generation of these pumps are limited by a number of factors that restrict their use to only the sickest of patients. The development and clinical use of the MicroMed DeBakey VAD represents a paradigm shift in the field of heart disease, supporting the notion that mechanical assistance can be achieved with continuous flow pumps. Axial flow devices, such as the DeBakey VAD, may open new doors for smaller patients and children, as well as improve the current standard of care for adults who require long-term circulatory support.

Development of mechanical heart devices.

BACKGROUND: A succinct, historical review of developments in mechanical devices to assist the failing heart is provided. METHODS: A number of methods of mechanical devices to assist the failing heart are briefly assessed. Personal experimental and clinical studies of devices developed over several decades are presented. RESULTS: Findings and data of devices used in assisting the failing heart, including those developed by the author, are analyzed. CONCLUSIONS: On the basis of this review, the left ventricular assist device is believed to be the most effective. There is also reason to believe that the axial flow system has considerable advantages. This form of therapy has potentially great value for permanent use in some patients with intractable heart failure.

Lessons learned from the first application of the DeBakey VAD Child: an intracorporeal ventricular assist device for children.

We report and describe the design and the first clinical implantation of the DeBakey ventricular assist device (VAD) Child, a pediatric intracorporeal left ventricular assist device, in a 6-year-old girl. The risk-benefit of novel technologies in advanced heart failure and the lessons learned by our experience are important to consider in hopes that other centers (where this device is now available) may benefit.

International Center for Medical Technologies acknowledges Artificial Organ Pioneers at the ASAIO-ISAO Joint Congress in 2003.

The International Center for Medical Technologies (ICMT), a museum for artificial organs in Houston, Texas, officially opened in November 2002, as previously published in Artificial Organs 2003;27(9):821-32. The museum expanded its original activities to formulate the International Academy for Artificial Organ Pioneers (Academy) and the International Faculty for Health and Medical Technologies (Faculty). At the joint American Society for Artificial Internal Organs (ASAIO) and International Society for Artificial Organs (ISAO) Congress in Washington, DC on June 18, 2003, Yukihiko Nosé introduced the ICMT and its formulation. The activities and future perspectives were presented by the ICMT Museum Director, Steven Phillips; the Academy Dean, Lowell Harmison; and the Faculty Dean, Michael E. DeBakey.

Surgical outcome in 85 patients with primary cardiac tumors.

BACKGROUND: We present a large, single institution experience with adult cardiac tumors and address factors affecting outcome. METHODS: A retrospective review was made of all patients who underwent surgery for primary cardiac tumors from April 1975 through August 2002. RESULTS: Eighty-five patients (33 male and 52 female) with a mean age of 54 years were identified with follow-up available for 80 (94%) patients. There were 68 (80%) benign tumors and 17 (20%) malignant tumors. Three tumors recurred and were resected giving a total of 88 surgeries. All benign tumors were grossly resected and the extent of resection for malignant disease ranged from 14 (78%) gross resections and 3 (17%) debulkings to 1 (5%) biopsy. There were 4 (5%) early hospital deaths. Median survival was 9.6 months and 322 months for patients with malignant and benign diseases, respectively. Significant predictors of long-term mortality were malignant disease (P <0.0001) and New York Heart Association class (P <0.03). CONCLUSIONS: Surgical resection provides excellent outcome in patients with benign cardiac tumors. Malignant tumors continue to pose a challenge with good local tumor control but limited survival owing to metastatic disease.