Identification of the disturbance and trajectory types in mining areas using multitemporal remote sensing images.

Surface coal mining disturbances affect the local ecology, human populations and environmental quality. Thus, much public attention has been focused on mining issues and the need for monitoring of environmental disturbances in mining areas. An automated method for identifying mining disturbances, and for characterizing recovery of vegetative cover on disturbed areas using multitemporal Landsat imagery is described. The method analyzes normalized difference vegetation index (NDVI) data to identify sample points with multitemporal spectral characteristics ("trajectories") that indicate the presence of environmental disturbances caused by mining. A typical disturbance template of mining areas is created by analyzing NDVI trajectories of disturbed points and used to describe NDVI multitemporal patterns before, during, and following disturbances. The multitemporal sequences of disturbed sample points are dynamically matched with the typical disturbance template to obtain information including the disturbance year, trajectory type, and the nature of vegetation recovery. The method requires manual analysis of randomly selected sample points from within the study area to calculate several thresholds; once those thresholds are determined, the method's application can be automated. We applied the method to a stack of 26 Landsat images over a 32-year period, 1984 to 2015, for mining areas of Martin County KY and Logan County WV in eastern USA. When compared with the samples determined by direct interpretation, the method identified mining disturbances with 97% accuracy, the disturbance year with 90% accuracy, and disturbance-recovery trajectory type with 90% accuracy.

Primary hyperparathyroidism with normal baseline intraoperative parathyroid hormone: A challenging population.

BACKGROUND: Patients with primary hyperparathyroidism and baseline intraoperative parathyroid hormone levels in the normal range are challenging. This study compares the predictive value of a commonly used intraoperative parathyroid hormone algorithm, a software model for cure prediction, and surgeon judgment in this population. METHODS: This was a retrospective review of consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism at a single institution from March 2013 to October 2014. RESULTS: Of 541 operative patients, 114 (21.1%) had a mean normal baseline intraoperative parathyroid hormone of ≤69 pg/mL (median 59.0 ± 10.3; range 26-69). Of the 114 patients, 93 (81.6%) were women, median age was 61 years (range 18-88). Overall, 107/108 (99.1%) patients were cured; 47 (41.2%) patients had single adenomas, 16 (14%) had double adenomas, and 51 (44.7%) had multigland hyperplasia. Using the 50% decline algorithm, a correct prediction was made in 86 (75.4%) patients. Using the computer software, a correct prediction was made in 88 (77.2%) patients. Surgeon judgment, however, was 99.1% accurate. CONCLUSION: Patients with normal baseline intraoperative parathyroid hormone have a high incidence of multigland disease (58.8%), greater than reported previously. Current software modeling and the 50% decline algorithm are insufficient to predict cure in this population; intraoperative parathyroid hormone interpretation combined with operative findings and surgical judgment yield optimal outcomes.

Quality improvement utilizing in-situ simulation for a dual-hospital pediatric code response team.

OBJECTIVE: Given the rarity of in-hospital pediatric emergency events, identification of gaps and inefficiencies in the code response can be difficult. In-situ, simulation-based medical education programs can identify unrecognized systems-based challenges. We hypothesized that developing an in-situ, simulation-based pediatric emergency response program would identify latent inefficiencies in a complex, dual-hospital pediatric code response system and allow rapid intervention testing to improve performance before implementation at an institutional level. METHODS: Pediatric leadership from two hospitals with a shared pediatric code response team employed the Institute for Healthcare Improvement's (IHI) Breakthrough Model for Collaborative Improvement to design a program consisting of Plan-Do-Study-Act cycles occurring in a simulated environment. The objectives of the program were to 1) identify inefficiencies in our pediatric code response; 2) correlate to current workflow; 3) employ an iterative process to test quality improvement interventions in a safe environment; and 4) measure performance before actual implementation at the institutional level. RESULTS: Twelve dual-hospital, in-situ, simulated, pediatric emergencies occurred over one year. The initial simulated event allowed identification of inefficiencies including delayed provider response, delayed initiation of cardiopulmonary resuscitation (CPR), and delayed vascular access. These gaps were linked to process issues including unreliable code pager activation, slow elevator response, and lack of responder familiarity with layout and contents of code cart. From first to last simulation with multiple simulated process improvements, code response time for secondary providers coming from the second hospital decreased from 29 to 7 min, time to CPR initiation decreased from 90 to 15 s, and vascular access obtainment decreased from 15 to 3 min. Some of these simulated process improvements were adopted into the institutional response while others continue to be trended over time for evidence that observed changes represent a true new state of control. CONCLUSIONS: Utilizing the IHI's Breakthrough Model, we developed a simulation-based program to 1) successfully identify gaps and inefficiencies in a complex, dual-hospital, pediatric code response system and 2) provide an environment in which to safely test quality improvement interventions before institutional dissemination.

Spatial and temporal relationships among watershed mining, water quality, and freshwater mussel status in an eastern USA river.

The Powell River of southwestern Virginia and northeastern Tennessee, USA, drains a watershed with extensive coal surface mining, and it hosts exceptional biological richness, including at-risk species of freshwater mussels, downstream of mining-disturbed watershed areas. We investigated spatial and temporal patterns of watershed mining disturbance; their relationship to water quality change in the section of the river that connects mining areas to mussel habitat; and relationships of mining-related water constituents to measures of recent and past mussel status. Freshwater mussels in the Powell River have experienced significant declines over the past 3.5 decades. Over that same period, surface coal mining has influenced the watershed. Water-monitoring data collected by state and federal agencies demonstrate that dissolved solids and associated constituents that are commonly influenced by Appalachian mining (specific conductance, pH, hardness and sulfates) have experienced increasing temporal trends from the 1960s through ~2008; but, of those constituents, only dissolved solids concentrations are available widely within the Powell River since ~2008. Dissolved solids concentrations have stabilized in recent years. Dissolved solids, specific conductance, pH, and sulfates also exhibited spatial patterns that are consistent with dilution of mining influence with increasing distance from mined areas. Freshwater mussel status indicators are correlated negatively with dissolved solids concentrations, spatially and temporally, but the direct causal mechanisms responsible for mussel declines remain unknown.

Reconstructing disturbance history for an intensively mined region by time-series analysis of Landsat imagery.

Surface mining disturbances have attracted attention globally due to extensive influence on topography, land use, ecosystems, and human populations in mineral-rich regions. We analyzed a time series of Landsat satellite imagery to produce a 28-year disturbance history for surface coal mining in a segment of eastern USA's central Appalachian coalfield, southwestern Virginia. The method was developed and applied as a three-step sequence: vegetation index selection, persistent vegetation identification, and mined-land delineation by year of disturbance. The overall classification accuracy and kappa coefficient were 0.9350 and 0.9252, respectively. Most surface coal mines were identified correctly by location and by time of initial disturbance. More than 8 % of southwestern Virginia's >4000-km(2) coalfield area was disturbed by surface coal mining over the 28-year period. Approximately 19.5 % of the Appalachian coalfield surface within the most intensively mined county (Wise County) has been disturbed by mining. Mining disturbances expanded steadily and progressively over the study period. Information generated can be applied to gain further insight concerning mining influences on ecosystems and other essential environmental features.

Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery.

BACKGROUND: Remedial cervical exploration for persistent or recurrent primary hyperparathyroidism can be technically difficult, but is expedited by accurate preoperative localization. We investigated the use of real-time super selective venous sampling (sSVS) in the setting of negative noninvasive imaging modalities. STUDY DESIGN: We performed a retrospective analysis of a prospective database incorporating real-time sSVS in a tertiary academic medical center. Between September 2001 and April 2014, 3,643 patients were referred for surgical treatment of primary hyperparathyroidism. Of these, 31 represented remedial patients who had undergone one (n=28) or more (n=3) earlier cervical explorations and had noninformative, noninvasive preoperative localization studies. RESULTS: We extended the use of the rapid parathyroid hormone assay in the interventional radiology suite, generating near real-time data facilitating onsite venous localization by a dedicated interventional radiologist. The predictive value of real-time sSVS localization was investigated. Overall, sSVS correctly predicted the localization of the affected gland in 89% of cases. Of 31 patients who underwent sSVS, a significant rapid parathyroid hormone gradient was identified in 28 (90%), localizing specific venous drainage of a culprit gland. All patients underwent subsequent surgery and were biochemically cured, with the exception of one who had metastatic parathyroid carcinoma. Three patients with negative sSVS were also explored and cured. CONCLUSIONS: Preoperative parathyroid localization is of paramount importance in remedial cervical explorations. Real-time sSVS is a sensitive localization technique for patients with persistent or recurrent primary hyperparathyroidism, when traditional noninvasive imaging studies fail. These results validate the utility and benefit of real-time sSVS in guiding remedial parathyroid surgery.

Paradigm shift in the surgical management of multigland parathyroid hyperplasia: an individualized approach.

IMPORTANCE: Locoregional anesthesia, conscious sedation, and exploration via a limited incision have become a well-accepted approach for the treatment of patients with primary hyperparathyroidism with image-localized, presumed single-gland disease. However, to our knowledge, this minimally invasive technique has never been investigated in patients with multigland disease. OBJECTIVE: To extrapolate the technique of locoregional anesthesia, conscious sedation, and exploration via a limited incision to perform minimally invasive bilateral exploration in patients who have multigland hyperplasia. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis at a tertiary academic referral center of 100 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism due to parathyroid hyperplasia between January 19, 2010, and July 30, 2013, who were included in a prospective database. INTERVENTIONS: All patients underwent subtotal parathyroidectomy using either conventional treatment (bilateral neck exploration under general anesthesia) or extended minimally invasive parathyroidectomy (ex-MIP; locoregional anesthesia, conscious sedation, and exploration via a limited incision). Patients in the ex-MIP group who required conversion to general anesthesia were analyzed in the ex-MIP group on an intent-to-treat basis. MAIN OUTCOMES AND MEASURES: Patient cure and complication rates, length of stay, and total hospital charges. RESULTS: Of the 100 consecutive patients with parathyroid hyperplasia, 29 received conventional treatment and 71 underwent ex-MIP. In the ex-MIP group, 11 of 71 patients (15.5%) required conversion to general anesthesia. There were no differences between the ex-MIP and conventional treatment groups in age (mean [SD], 62.2 [12.2] vs 57.7 [15.2] years; P = .12), sex (59 [83.1%] vs 23 [79.3%] female; P = .78), preoperative serum calcium level (mean [SD], 11.1 [0.9] vs 10.8 [0.8] mg/dL; to convert to millimoles per liter, multiply by 0.25; P = .15), preoperative serum parathyroid hormone level (mean [SD], 114.5 [56.8] vs 137.8 [83.4] pg/mL; to convert to nanograms per liter, multiply by 1; P = .10), complications (4 vs 0 complications; P = .32), or cure rates (98.6% vs 96.6%; P = .50). Importantly, the ex-MIP group had a significant reduction in length of stay compared with the conventional treatment group (mean [SD], 1.01 [0.02] vs 1.35 [0.24] days; P = .04). They also had lower total hospital charges, but the difference was not statistically significant (mean, $23,199 vs $27,312; P = .17). CONCLUSIONS AND RELEVANCE: Parathyroidectomy with bilateral neck exploration under general anesthesia has been the standard of care for the treatment of parathyroid hyperplasia. We demonstrate that ex-MIP can provide equivalent cure and complication rates with a shorter hospital stay and a mean hospital charge reduction of more than $4000 per case.

Cure predictability during parathyroidectomy.

BACKGROUND: A mathematical model for primary hyperparathyroidism (1°HPTH) was developed and embedded in software to yield intraoperative predictability curves. METHODS: A total of 1,754 consecutive 1°HPTH operative cases were screened to select 617 [554 single adenoma (SA), 63 multigland] patients with complete preoperative, intraoperative (pre-exploration, time 0, every 5 min post-resection), and postoperative parathyroid hormone (PTH) and calcium data. Data transformations and models were hypothesized and tested, including inverse functions, differences, half-lives, differences from projected half-lives, second-order kinetics, second-order derivatives, and time-dependent ratios. Sub-models of ratios were developed for time-dependent and initial-value combinations. For each time segment the log odds were modeled using multiple logistic stepwise regression. An idealized model was selected, embedded in software, and installed in a laptop computer to enable intraoperative decision analyses, PTH curve plotting, and storage and transmission of data. A subsequent cohort of 100 consecutive unselected patients [81 SAs, 19 multigland (13 hyperplasia, 2 MEN1, 1 lithium, 3 double adenomas)] inclusive of seven remedial cervical explorations were tested. RESULTS: The model predicted an overall curative resection in 95 % of patients. In SA patients, cure was predicted in 78/81 patients with a mean probability of 99.3 % at 11.8 ± 10.4 min post-resection. In three cured patients, the software failed to suggest cure, because of a low baseline PTH or delayed clearance. The model also correctly predicted residual hyperfunctioning tissue in all tested multigland patients. All multigland patients underwent additional exploration with resection of residual disease resulting in a mean predicted cure rate of 97.9 % at 10.6 ± 7.3 min post-resection completion in 17 patients. In two patients, the software predicted a mean cure rate of 22 % due to either a low PTH baseline or delayed clearance. Overall, the software accurately predicted cure in 95 of 100 cured cases. CONCLUSIONS: This intraoperative prediction software expedites termination of surgery with a high level of curative confidence. Alternatively, the model accurately predicts residual disease prompting additional exploration. Because the model is based on a large set of multivariate regression curves, PTH values obtained at any post-resection sampling interval generate prediction data with far greater accuracy than existing algorithms. The software is designed for convenient operative use and can print, store, and electronically transmit probability analyses and PTH curves in real-time.

Laryngeal physiology and voice acoustics are maintained after minimally invasive parathyroidectomy.

OBJECTIVES: This prospective single-arm study investigated both laryngeal physiology and voice acoustic measures in patients undergoing minimally invasive parathyroidectomy (MIP) due to primary hyperparathyroidism (primary HPTH). BACKGROUND: Avoidance of recurrent or superior laryngeal nerve injury and maintenance of normal laryngeal physiology and vocal function are key goals in the treatment of primary HPTH. No data are available comparing pre- and postoperative MIP laryngeal physiology and voice acoustics. METHODS: Patients served as their own controls and underwent identical pre- and postoperative assessment. True vocal fold mobility was assessed and recorded using transnasal fiber-optic laryngoscopy. Vocal capacity was recorded with maximum phonation time and vocal stability by frequency-based voice measures, that is, mean fundamental frequency (F0), standard deviation of the fundamental frequency (F0SD), and jitter and shimmer as measured by relative average perturbation and mean shimmer in decibels, respectively. RESULTS: A total of 104 patients were enrolled [26 men, mean age = 53 years, range 29-79 years; 78 women, mean age = 56 years, range 16-83 years). All completed the protocol and were analyzed according to intent to treat. MIP was accomplished in 95 patients, and 9 were converted to general anesthesia. The cure rate was 100%, as evidenced by normalization of serum calcium levels. Both real-time agreement and blinded inter- and intrarater reliability testing for laryngeal physiology ratings were 100%. One patient (<1%) exhibited a recurrent laryngeal nerve injury. No significant differences (P > 0.05) were found for any voice acoustic parameter between pre- and postoperative MIP (ie, maximum phonation time, F0, F0SD, relative average perturbation, or shimmer in decibels). CONCLUSIONS: MIP can be performed with exquisite disease control and without significant effects on laryngeal physiology or voice acoustic measures. For the first time, both physiologic and acoustic data support the use of MIP.

Effect of patient Age on surgical outcomes for Graves' disease: a case-control study of 100 consecutive patients at a high volume thyroid surgical center.

OBJECTIVE: To compare outcomes between children (<18 yrs) and adults undergoing total thyroidectomy for Graves' disease (GD) at a high volume, multidisciplinary thyroid center. SUMMARY OF BACKGROUND DATA: Reported complication rates for children undergoing surgery for Graves' disease are worse than for adults. METHODS: 100 consecutive patients (32 children; 68 adults) who underwent total thyroidectomy for Graves' disease (GD) by a high-volume endocrine surgery team from were compared. RESULTS: The mean patient age was 9.7 yrs (range 3.4-17.9 yrs) in children versus 44.9 yrs (range 18.4-84.2 yrs) in adults. Operative times were longer in children (2.18 ± 0.08 hrs) than in adults (1.66 ± 0.03 hrs) (p = 0.003). Pediatric thyroid specimens averaged 38.6.0 ± 8.9 gm (range: 9-293 gm) and adult thyroid specimens averaged 48.0 ± 6.4 gm (range: 6.6-203 gm) (p = 0.34). Thyroid to body weight ratios were greater in children (0.94 ± 0.11 gm/kg) than adults (0.67 ± 0.8 gm/kg) (p = 0.05). In all patients, the hyperthyroid state resolved after surgery. There was no operative mortality, recurrence, or permanent hypoparathyroidism. Transient post-operative hypocalcemia requiring calcium infusion was greater in children than adults (6/32 vs. 1/68; p = 0.004). Transient recurrent laryngeal nerve dysfunction occurred in two children and in no adults (p = 0.32). Postoperative hematoma occurred in two adults and in no children (p = 0.46). The length of stay was longer for children (1.41 ± 0.12 days) than for adults (1.03 ±0.03 days) (p = 0.004). CONCLUSION: Surgical management of GD is technically more challenging in children as evidenced by longer operative times. Whereas temporary hypocalcemia occurs more commonly in children than adults, the risks of major complications including disease recurrence, permanent hypoparathyroidism, recurrent laryngeal nerve injury, or neck hematoma were indistinguishable. These data suggest that excellent and equivalent outcomes can be achieved for GD surgery in children and adults when care is rendered by a high volume, endocrine surgery team.

Surgical approach and outcomes in patients with lithium-associated hyperparathyroidism.

BACKGROUND: Patients receiving lithium therapy are at elevated risk of developing hyperparathyroidism. In lithium-associated hyperparathyroidism (LAH), the incidence of multiglandular disease (MGD) is unclear, and the need for routine bilateral cervical exploration remains controversial. Therefore, in LAH patients, surgical approaches, pathologic findings, cure rates, and factors associated with persistent or recurrent disease were investigated. METHODS: Retrospective analysis of 27 patients with LAH undergoing parathyroidectomy with the intraoperative parathyroid hormone (PTH) assay. RESULTS: The median postoperative follow-up was 7 months; 17 patients had >6 months follow-up. Cervical exploration was unilateral in 9, bilateral in 18 (3 were converted from unilateral). Sixteen patients (62%) had MGD, 12 with four-gland hyperplasia and 4 with double adenomas. Ten patients (38%) had a single adenoma. Twenty-five (93%) of 27 patients had initially successful surgery. Of the 17 patients with >6 months follow-up, two had persistent disease and two experienced recurrent disease. All patients with a single adenoma remain free of disease. Three (75%) of four patients with persistent/recurrent disease had MGD and were receiving lithium at the time of surgery. Patients with persistent/recurrent disease were older (p = 0.01) and had experienced a longer duration of hypercalcemia (p = 0.04). CONCLUSIONS: LAH patients have a high incidence of MGD, and bilateral exploration is frequently necessary. With access to the intraoperative PTH assay, it is reasonable to initiate a unilateral approach because many patients will harbor single adenomas and can be reliably rendered normocalcemic. Patients with MGD remain at higher risk of persistent/recurrent disease.

Frequent germ-line mutations of the MEN1, CASR, and HRPT2/CDC73 genes in young patients with clinically non-familial primary hyperparathyroidism.

Familial primary hyperparathyroidism (FPHPT) may occur due to an underlying germ-line mutation in the MEN1, CASR, or HRPT2/CDC73 genes. The disease may be undiagnosed in the absence of a history suggestive of FHPT. Young PHPT patients (≤45 years of age) are more likely to harbor occult FPHPT. A total of 1,161 (136 were ≤45 years of age) PHPT patients underwent parathyroidectomy from 2001 to 2009. Thirty-four patients declined participation. Sixteen patients were diagnosed in the clinical routine with FPHPT (11 MEN1, four MEN2A, and one HPT-JT) and were not included in the genetic analysis. Eighty-six young (≤45 years of age) patients with clinically non-syndromic PHPT underwent genetic analysis. Sanger sequencing of all coding regions of the MEN1, CASR, and the HRPT2/CDC73 genes was performed. Eight of 86 (9.3%) young patients with clinically non-familial PHPT displayed deleterious germ-line mutations in the susceptibility genes (4 MEN1, 3 CASR, and 1 HRPT2/CDC73). There was one insertion, one deletion, two nonsense, and four missense mutations, all predicted to be highly damaging to protein function and absent in 3,244 control chromosomes. Germ-line mutations in known susceptibility genes within young patients with PHPT, including those diagnosed in the clinical routine, was 24/102 (23.5%; 15 MEN1, four RET, three CASR, and two HRPT2/CDC73). We demonstrate that germ-line inactivating mutations in susceptibility genes are common in young patients with clinically non-familial PHPT. Thus, enhanced use of genetic analysis may be warranted in clinically non-familial young PHPT patients.

The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism.

OBJECTIVE: To compare the results of minimally invasive parathyroidectomy (MIP) and conventional parathyroid surgery. BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder often treated by surgical intervention. Outpatient MIP, employing image-directed focused exploration under cervical block anesthesia, has replaced traditional surgical approaches for many patients with primary hyperparathyroidism. This retrospective review of a prospective database compared MIP with conventional parathyroid surgery. METHODS: One thousand six hundred fifty consecutive patients underwent surgery for primary hyperparathyroidism by a single surgeon between 1990 and 2009 at 2 tertiary care academic hospitals. Conventional bilateral cervical exploration under general anesthesia was performed in 613 patients and MIP was performed in 1037 cases. Cure rates, complication rates, pathologic findings, length of hospital stay, and total hospital costs were compared. RESULTS: Minimally invasive parathyroidectomy is associated with improvements in the cure rate (99.4%) and the complication rate (1.45%) compared to conventional exploration with a cure rate of 97.1% and a complication rate of 3.10%. In addition, the hospital length of stay and total hospital charges were also improved compared to conventional surgery. CONCLUSIONS: Minimally invasive parathyroidectomy is a superior technique and should be adopted for the majority of patients with sporadic primary hyperparathyroidism.

Evaluating terrestrial carbon sequestration options for Virginia.

Changes in forest and agricultural land management practices have the potential to increase carbon (C) storage by terrestrial systems, thus offsetting C emissions to the atmosphere from energy production. This study assesses that potential for three terrestrial management practices within the state of Virginia, USA: afforestation of marginal agricultural lands; afforestation of riparian agricultural lands; and changing tillage practices for row crops; each was evaluated on a statewide basis and for seven regions within the state. Lands eligible for each practice were identified, and the C storage potential of each practice on those lands was estimated through a modeling procedure that utilized land-resource characteristics represented in Geographic Information System databases. Marginal agricultural lands' afforestation was found to have the greatest potential (1.4 Tg C yr(-1), on average, over the first 20 years) if applied on all eligible lands, followed by riparian afforestation (0.2 Tg C yr(-1) over 20 years) and tillage conversion (0.1 Tg C yr(-1) over 14 years). The regions with the largest potentials are the Ridge and Valley of western Virginia (due to extensive areas of steep, shallow soils) and in the Mid-Atlantic Coastal Plain in eastern Virginia (wet soils). Although widespread and rapid implementation of the three modeled practices could be expected to offset only about 3.4% of Virginia's energy-related CO(2) emissions over the following 20 years (equivalent to about 8.5% of a Kyoto Treaty-based target), they could contribute to achievement of C-management goals if implemented along with other mitigation measures.

Sonographically guided fine needle aspiration with rapid parathyroid hormone assay.

BACKGROUND: Persistent or recurrent primary hyperparathyroidism (1 degrees HPTH) is ideally treated with limited dissection, based on accurate localization, to minimize operative risks. To accurately localize parathyroid tissue, we employed ultrasound-guided fine needle aspiration (US FNA) with an on-site rapid parathyroid hormone (PTH) assay to confirm localization. METHODS: Of the 272 patients evaluated for 1 degrees HPTH, 34 had persistent or recurrent disease. Standard localization was equivocal in 12, who were referred for US FNA. Suspicious tissue was identified on US and FNA was performed. Analysis with a rapid PTH assay provided on-site result within 12 min. Patients were monitored clinically, and then discharged after observation. RESULTS: Twelve patients were referred for US FNA; eight were female. Ten patients had persistent disease, one had recurrent, and one had 1 degrees HPTH following thyroidectomy. Two of the 12 were excluded due to negative ultrasound examination. Of the remaining ten, positive aspirates were found in nine, and seven proceeded to surgery. In six patients there was 100% correlation between sonographic and operative findings. The remaining patient had no identifiable adenoma, but PTH normalized after arterial ligation. All patients received a limited directed surgical approach, employing cervical block anesthesia in three. Four were discharged on the day of surgery and all were cured. There was one infectious complication of US FNA. CONCLUSIONS: The use of rapid PTH assay can be effectively utilized for localization of parathyroid tissue in remedial parathyroid surgery. Confirmation of localization markedly improves subsequent surgery and allows selective use of minimally invasive techniques.

Remedial parathyroid surgery: changing trends in 130 consecutive cases.

OBJECTIVE: To review the outcomes in 130 consecutive remedial explorations for primary hyperparathyroidism. SUMMARY BACKGROUND DATA: Remedial surgery for primary hyperparathyroidism is challenging and requires meticulous preoperative evaluation and imaging to expedite a focused surgical exploration that has traditionally been performed under general anesthesia. This prospective series of 130 consecutive remedial operations for primary hyperparathyroidism selectively used minimally invasive techniques and tested the hypothesis that these techniques could improve outcomes. METHODS: Between 1990 and 2005, 1,090 patients were evaluated and explored for primary hyperparathyroidism. Of these, 130 remedial explorations were performed in 128 patients who underwent either conventional exploration under general anesthesia (n = 107) or minimally invasive parathyroidectomy (n = 23) employing cervical block anesthesia, directed exploration, and curative confirmation with the rapid intraoperative parathyroid hormone assay. RESULTS: The sensitivity of preoperative imaging were: Sestamibi (79%), ultrasound (74%), MRI (47%), CT (50%), venous localization (93%), and ultrasound guided parathyroid fine needle aspiration (78%). The cure rate in the conventional remedial group (n = 107) was 94% and was associated with a mean length of stay of 1.6 +/- 0.2 days. Remedial exploration employing minimally invasive techniques (n = 23) resulted in a cure rate of 96% and a mean length of stay of 0.4 +/- 0.1 days. Complications were rare in both remedial groups. These results were almost identical to those achieved in 960 unexplored patients. CONCLUSIONS: Remedial parathyroid surgery can be accomplished with acceptable cure and complication rates. Minimally invasive techniques can achieve outcomes that are similar to those obtained in unexplored patients.