Normocalcemic and Normohormonal Primary Hyperparathyroidism: Laboratory Values and End-Organ Effects.

OBJECTIVE: Variants of primary hyperparathyroidism (pHPT), described as normocalcemic (NC) and normohormonal (NH), can confuse the diagnosis of classic pHPT. DATA SOURCES: A MEDLINE search was performed for variants of pHPT using the PubMed database (last queried October 2019). REVIEW METHODS: The search was restricted to articles published after 1960 that were specific to humans. Studies were included in our analysis if laboratory values and incidence of end-organ involvement were reported for NCpHPT and NHpHPT variants. The search returned 189 articles; 27 additional studies were identified and included for a total of 216. Non-English-language studies were excluded. Abstracts were screened, full-text articles were then assessed, and 82 articles were excluded. Data were pooled using a random-effects model in studies that compared NC or NH pHPT to classic pHPT. Comparative laboratory values are presented. CONCLUSION: This analysis compares NCpHPT and NHpHPT to classic pHPT. Nephrolithiasis was 21.7% (NCpHPT), 15.9% (classic pHPT), and 25.4% (NHpHPT). Decreased bone mineral density was 49.7% (NCpHPT), 39.7% (classic pHPT), and 40.3% (NHpHPT). Fractures in the NCpHPT group were not significantly different from the classic pHPT. Hypertension in the NCpHPT group was significantly less than classic pHPT (odds ratio, 0.59; 95% CI, 0.40-0.88). IMPLICATIONS FOR CLINICAL PRACTICE: This information may serve to inform clinicians of the laboratory subtleties of these variants that are being seen with greater frequency in contemporary practice.

Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol.

BACKGROUND: Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid. METHODS: Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids. RESULTS: Post-ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre-ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre-ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post-ERAS study patients were prescribed opioids with 84.8% filled. CONCLUSION: Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.

Lightly Embalmed Cadavers as a Training Tool for Ultrasound-Guided Procedures Commonly Used in Interventional Radiology.

RATIONALE AND OBJECTIVES: Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care. MATERIALS AND METHODS: Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access. RESULTS: The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient. CONCLUSION: Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Trends in Intraoperative Testing During Cochlear Implantation.

OBJECTIVE: No consensus guidelines exist regarding intraoperative testing during cochlear implantation and wide variation in practice habits exists. The objective of this observational study was to survey otologists/neurotologists to understand practice habits and overall opinion of usefulness of intraoperative testing. STUDY DESIGN: Cross-sectional survey. SETTING: A web-based survey was sent to 194 practicing Otologists/Neurotologists. MAIN OUTCOME MEASURES: Questions included practice setting and experience, habits with respect to electrodes used, intraoperative testing modalities used, overall opinion of intraoperative testing, and practice habits in various scenarios. RESULTS: Thirty-nine of 194 (20%) completed the survey. For routine patients, ECAPs and EIs were most commonly used together (38%) while 33% do not perform testing at all. Eighty-nine percent note that testing "rarely" or "never" changes management. Fifty-one percent marked the most important reason for testing is the reassurance provided to the family and/or the surgeon. CONCLUSION: Intraoperative testing habits and opinions regarding testing during cochlear implantation vary widely among otologic surgeons. The majority of surgeons use testing but many think there is minimal benefit and that surgical decision-making is rarely impacted. The importance of testing may change as electrodes continue to evolve.

Dedifferentiated Liposarcoma Mimicking a Primary Colon Mass.

Dedifferentiated liposarcoma is typically a nonlipogenic high-grade sarcoma that arises from well-differentiated liposarcoma. It most commonly presents as a large mass in the retroperitoneum. Significant involvement of the gastrointestinal tract by dedifferentiated liposarcoma is uncommon. We present a unique case of dedifferentiated liposarcoma radiographically mimicking a primary colon mass with resulting intussusception; stranding of the adjacent adipose tissue was presumed to be a secondary reactive change. On histopathologic analysis of the hemicolectomy specimen, a high-grade sarcoma was seen growing through the colonic wall, and the majority of the surrounding pericolonic adipose tissue was actually composed of well-differentiated liposarcoma with characteristic fibrous bands rather than benign fat with reactive fibrosis. This case raises awareness that well-differentiated liposarcoma and dedifferentiated liposarcoma can rarely present as a primary intestinal mass mimicking colon cancer or other more common entities. When radiographic examination shows a perigastrointestinal or retroperitoneal fatty mass and/or stranding of the fat adjacent to a solid gastrointestinal mass, this unusual scenario should be considered in the radiologic differential diagnosis. Pathologists should keep dedifferentiated liposarcoma in the initial histologic differential diagnosis for any high-grade spindle cell tumor of the retroperitoneum or intra-abdominal visceral organs.