Parathyroid hormone-driven algorithms after thyroid surgery: Not one-size-fits-all.

BACKGROUND: Underreported variation in parathyroid hormone (PTH) assays exists. Using quality improvement methods, we aimed to develop an institution-specific PTH-based protocol to predict hypocalcemia after thyroidectomy. METHODS: We retrospectively reviewed patients who underwent total/completion thyroidectomy. A receiver operating curve (ROC) determined postoperative PTH cut-offs predictive of hypocalcemia. The stakeholders developed PTH-driven calcium management guidelines. Post-implementation outcomes were prospectively measured. RESULTS: Pre-implementation, 95 patients were assessed. PTH ≤1.5 pmol/L (14.1 pg/ml) predicted hypocalcemia (96%sensitivity), and ≥2.8 pmol/L (26.4 pg/ml) predicted normocalcemia (99%specificity) (area under curve = 0.97, SEM = 0.018). PTH on the day of and morning after surgery were identically predictive. Post-implementation, 64 patients were assessed. Hypocalcemia occurred with PTH >2.8 pmol/L in 2 cases (3.1%). Calcium over-prescribing decreased from 13.7% to 3.1% (p = 0.06). Length of stay (LOS) > 2 nights decreased from 13% to 3.1% (p = 0.05). CONCLUSION: A PTH-driven calcium management protocol post-thyroidectomy effectively reduces unnecessary calcium replacement and LOS. Given the variability in PTH assays, each institution may need to use individual cut-offs.

Pilot study to determine barriers to accessing sinus surgery.

OBJECTIVE: Given that anecdotal evidence has suggested that certain groups of patients have difficulty accessing sinus surgery, this study aimed to discover the characteristics and access factors that deter patients from surgery. SETTING: Patients were recruited from a community, academic otolaryngology-head and neck surgery practice serving a diverse community. DESIGN: In this cross-sectional study, patients with chronic sinusitis completed a pilot-tested questionnaire. We compared patients who already had sinus surgery to those who had not. MAIN OUTCOME MEASURES: The measured outcomes were descriptive statistics regarding patient demographics and direct ability to obtain sinus surgery. RESULTS: Of those surveyed, 26 patients had undergone surgery, whereas 18 patients had not. There were no differences between groups in terms of ability to speak English; however, there was a smaller component of employed patients in the presurgery group compared to the postoperative group. Age and ethnicity differed between groups, with more North American-born, younger patients in the presurgery group. The ability to afford medications postoperatively or to take time off work for surgery did not differ between groups. Eighty percent of all patients said that they would not be able to take 2 weeks off work. CONCLUSIONS: We found that ethnicity and work status differed between patients offered surgery and those who have already undergone sinus surgery. Given that many patients reported difficulties in several access areas despite undergoing surgery, it seems that there are barriers to patients scheduling surgery that are being overcome by some.

Clinical experience with angulated, hand-activated, wireless instruments in an optical tracking system for endoscopic sinus surgery.

OBJECTIVES: Image-guided surgery of the paranasal sinuses has become a valuable tool in endoscopic sinus surgery. Optical image-guided systems using infrared tracking technology are widely used. We present our experience with new angulated, hand-activated, wireless instruments in an optical tracking system for endoscopic sinus surgery. DESIGN: Case series. SETTING: Community university teaching hospital. METHODS: Sixty-five consecutive patients underwent computer-assisted endoscopic sinus surgery using a Stryker Navigation System (Stryker Canada LP, Burlington, ON). Patients underwent preoperative fine-cut axial computed tomography. At the time of surgery, anatomic fiducials were registered and the measured fiducial registration error (FRE), which is an indicator of the accuracy of the optical system, was recorded. Angulated battery-powered active instrumentation was used during the surgery. MAIN OUTCOME MEASURES: FRE, the number of anatomic fiducials used, complication rates pre- and postuse of computer-assisted sinus surgery. RESULTS: The mean FRE was 2.02 +/- 0.48 mm. The mean number of anatomic fiducials used for registration was 5.98. There were no major orbital or intracranial complications. Use of angulated instruments rarely caused a line of sight problem. CONCLUSIONS: The new optical system has a measured FRE comparable to that of other image guidance systems. Our clinical experience shows that the instrumentation decreases the "line of sight" problem and is easy to navigate and manipulate without a wire attachment to the main computer.