Spatial and temporal analysis of road traffic crashes and ambulance responses in Lagos state, Nigeria.

BACKGROUND: Sub-Saharan African countries, Nigeria inclusive, are constrained by grossly limited access to quality pre-hospital trauma care services (PTCS). Findings from pragmatic approaches that explore spatial and temporal trends of past road crashes can inform novel interventions. To improve access to PTCS and reduce burden of road traffic injuries we explored geospatial trends of past emergency responses to road traffic crashes (RTCs) by Lagos State Ambulance Service (LASAMBUS), assessed efficiency of responses, and outcomes of interventions by local government areas (LGAs) of crash. METHODS: Using descriptive cross-sectional design and REDcap we explored pre-hospital care data of 1220 crash victims documented on LASAMBUS intervention forms from December 2017 to May 2018. We analyzed trends in days and times of calls, demographics of victims, locations of crashes and causes of delayed emergency responses. Assisted with STATA 16 and ArcGIS pro we conducted descriptive statistics and mapping of crash metrics including spatial and temporal relationships between times of the day, seasons of year, and crash LGA population density versus RTCs incidence. Descriptive analysis and mapping were used to assess relationships between 'Causes of Delayed response' and respective crash LGAs, and between Response Times and crash LGAs. RESULTS: Incidences of RTCs were highest across peak commuting hours (07:00-12:59 and 13:00-18:59), rainy season and harmattan (foggy) months, and densely populated LGAs. Five urban LGAs accounted for over half of RTCs distributions: Eti-Osa (14.7%), Ikeja (14.4%), Kosofe (9.9%), Ikorodu (9.7%), and Alimosho (6.6%). On intervention forms with a Cause of Delay, Traffic Congestion (60%), and Poor Description (17.8%), had associations with LGA distribution. Two densely populated urban LGAs, Agege and Apapa were significantly associated with Traffic Congestion as a Cause of Delay. LASAMBUS was able to address crash in only 502 (36.8%) of the 1220 interventions. Other notable outcomes include: No Crash (false calls) (26.6%), and Crash Already Addressed (22.17%). CONCLUSIONS: Geospatial analysis of past road crashes in Lagos state offered key insights into spatial and temporal trends of RTCs across LGAs, and identified operational constraints of state-organized PTCS and factors associated with delayed emergency responses. Findings can inform programmatic interventions to improve trauma care outcomes.

Burnout in Surgical Residents of Underrepresented in Medicine Backgrounds: Key Influencing Factors and Possible Solutions.

INTRODUCTION: Alarming rates of burnout in surgical training pose a concern due to its deleterious effects on both patients and providers. Datum remains lacking on rates of burnout in surgical residents based on race and ethnicity. This study aims to document the frequency of burnout in surgical residents of racially underrepresented backgrounds and elucidate contributing factors. METHODS: A 35-question anonymized survey was distributed to general surgery residents from 23 programs between August 2018 and May 2019. This survey was designed from the validated Maslach Burnout Inventory, and included additional questions assessing participant demographics, educational, and social backgrounds. Responses were analyzed utilizing chi-square tests and Wilcoxon rank sum tests. There was also a free response portion of the survey which was evaluated using thematic analysis. RESULTS: We received 243 responses from 23 general surgery programs yielding a 9% (23/246) program response rate and 26% (243/935) response rate by surgical residents. One hundred and eighty-five participants (76%) identified as nonunderrepresented in medicine and 58 (24%) of participants identified as underrepresented in medicine. Fifty-three percent were male and 47% female. Overall, sixty-six percent of all surgical residents (n = 161) endorsed burnout with racially underrepresented residents reporting higher rates of burnout at 76% compared to 63% in their nonunderrepresented counterparts (P = 0.07). CONCLUSIONS: Although the generalizability of these results is limited, higher rates of reported burnout in racially underrepresented trainees noted in our study illuminates the need for continual dialogue on potential influencing factors and mitigation strategies.

Using parallel geocoding to analyse the spatial characteristics of road traffic injury occurrences across Lagos, Nigeria.

While efforts to understand and mitigate road traffic injury (RTI) occurrence have long been underway in high-income countries, similar projects in low/middle-income countries (LMICs) are frequently hindered by institutional and informational obstacles. Technological advances in geospatial analysis provide a pathway to overcome a subset of these barriers, and in doing so enable researchers to create actionable insights in the pursuit of mitigating RTI-associated negative health outcomes. This analysis develops a parallel geocoding workflow to improve investigation of low-fidelity datasets common in LMICs. Subsequently, this workflow is applied to and evaluated on an RTI dataset from Lagos State, Nigeria, minimising positional error in geocoding by incorporating outputs from four commercially available geocoders. The concordance between outputs from these geocoders is evaluated, and spatial visualisations are generated to provide insight into the distribution of RTI occurrence within the analysis region. This study highlights the implications of geospatial data analysis in LMICs facilitated by modern technologies on health resource allocation, and ultimately, patient outcomes.

Assessment of Knowledge, Skills, and Preparedness of General-Duty Police on Prehospital Care of Road Traffic Accident Victims in Abuja, Nigeria.

OBJECTIVES: Prompt prehospital care (PHC) is essential for improving outcomes of road traffic accident victims. Previous studies in Nigeria show that little or no PHC is delivered to trauma victims by first responders. This study was conducted to assess police officers' experience with FA/BLS, to identify gaps in their FA/BLS knowledge and skills, and assess police stations' FA/BLS equipment capacity for PHC of road traffic accident victims. METHODS: This cross-sectional study was conducted among 428 GD police in Abuja between November and December 2018. Respondents were selected using stratified random sampling with proportional allocation method. Data were collected using self-administered electronic semi-structured questionnaires. Data analysis was done using STATA v 14.0 (StataCorp, College Station, TX). Chi-square and multivariate logistic regression were used to assess associations. RESULTS: We analyzed data from 419 respondents. Almost all (90.2%) of the police were aware of FA/BLS. The proportion of police with poor, fair, and good knowledge and skills on FA/BLS were 15.3%, 79.0%, and 5.7%, respectively. Tertiary (OR = 3.35, 95% CI: 1.01-11.11, P = 0.048) and postgraduate (OR = 6.89, 95% CI: 1.63-29.19, P = 0.009) levels of education had statistically significant association with good knowledge and skills. CONCLUSION: This highlights the need to implement an educational intervention to increase FA/BLS competencies within the first responder population.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism.

OBJECTIVE: To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND: Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS: Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS: These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS: Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Complications of traditional bonesetting in contemporary fracture care in low- and middle-income countries: A systematic review.

OBJECTIVE: To provide an overview of the evidence on the prevalence and pattern of complications among patients treated by traditional bonesetting presenting for modern orthopaedic services in low- and middle-income countries (LMIC). METHODS: Systematic review following PRISMA guidelines. Articles were identified by searching PubMed, Embase, ScienceDirect, SCOPUS, and Web of Science using the keywords "fracture care", "traditional bonesetters" and "complications". Papers included for review were original articles set in an LMIC that directly reported the prevalence and pattern of musculoskeletal complications of traditional bonesetters' fracture treatment in LMIC settings. RESULTS: A total of 176 papers were screened for eligibility and 15 studies were finally included. Nine were prospective studies, six were retrospective studies. All were hospital-based, observational studies that investigated the outcomes of treatment of fractures by traditional bonesetters published between 1986 and 2018. In total, this review covers 1389 participants with 1470 complications of fracture treatment. CONCLUSION: Traditional bonesetting complications are associated with significant morbidity. However, traditional bonesetters have the potential to contribute positively to primary fracture care when they are trained.

Global community perception of 'surgical care' as a public health issue: a cross sectional survey.

BACKGROUND: In the last decade surgical care has been propelled into the public health domain with the establishment of a World Health Organisation (WHO) designated programme and key publications. The passing of the historic World Health Assembly Resolution (WHA) acknowledged surgical care as a vital component towards achieving Universal Health Coverage (UHC). We conducted the first worldwide survey to explore the perception of surgical care as a public health issue. METHOD: The anonymous, cross sectional survey targeted worldwide participants across a range of professional backgrounds, including non-medical using virtual snowball sampling method (in English) using Google Forms (Google Inc., Mountain View, CA, USA) from 20th February 2019 to 25th June 2019. The survey questions were designed to gauge awareness on Sustainable Development Goals (SDGs), UHC, WHO programmes and key publications on surgical care as well as perception of surgical care as a priority topic in public health. RESULTS: The survey was completed by 1954 respondents from 118 countries. Respondents were least aware of surgical care as a teaching topic in public health courses (27%; n = 526) and as a WHO programme (20%; n = 384). 82% of respondents were aware of UHC (n = 1599) and of this 72% (n = 1152) agreed that surgical care fits within UHC. While 77% (n = 1495) of respondents were aware of SDGs, only 19% (n = 370) agreed that surgery was a priority to meet SDGs. 48% (n = 941) rated surgical care as a cost-effective component of Primary Health Care. 88% (n = 1712) respondents had not read the WHA Resolution on 'Strengthening emergency and essential surgical care and anaesthesia as a component of UHC'. CONCLUSION: There is still a widespread gap in awareness on the importance of surgical care as a public health issue amongst our respondents. Surgical care was not seen as a priority to reach the SDGs, less visible as a WHO programme and not perceived as an important topic for public health courses.

Lagos state ambulance service: a performance evaluation.

OBJECTIVES: The mortality rate from road traffic accidents (RTAs) in Nigeria is almost double that of the USA. In Nigeria, the first emergency medical services (EMS) system was established in March 2001, The Lagos State Ambulance Service (LASAMBUS). The objectives of this study are to (1) determine the burden of RTAs in Lagos, (2) assess RTA call outcomes, and (3) analyze LASAMBUS's response time and causes for delay. METHODOLOGY: We reviewed completed LASAMBUS intervention forms spanning December 2017 to May 2018. We categorized the call outcomes into five groups: I. Addressed Crash, II. No Crash (False Call), III. Crash Already Addressed, IV. Did Not Respond, and V. Other. We further explored associations between the (1) causes for delay and outcomes and (2) response times and the outcomes. RESULTS: Overall, we analyzed 1352 intervention forms. We found that LASAMBUS did not address 53% of the RTA calls that they received. Of this, Outcome II. No Crash (False Call) accounted for 26% and Outcome III. Crash Already Addressed accounted for 22%. Self-reported causes for delay were recorded in 180 forms, representing 13.7% of the RTA burden. Traffic congestion accounted for 60% of this distribution. CONCLUSION: LASAMBUS response rates are significantly lower than response rates in high-income countries such as the USA and lead to increased RTA mortality rates. Eliminating causes for delay will improve both LASAMBUS effectiveness and RTA victims' health outcomes. Changing the public perception of LASAMBUS and standardizing LASAMBUS' contact information will aid this as well.

Phosphoprotein-based biomarkers as predictors for cancer therapy.

Disparities in cancer patient responses have prompted widespread searches to identify differences in sensitive vs. nonsensitive populations and form the basis of personalized medicine. This customized approach is dependent upon the development of pathway-specific therapeutics in conjunction with biomarkers that predict patient responses. Here, we show that Cdk5 drives growth in subgroups of patients with multiple types of neuroendocrine neoplasms. Phosphoproteomics and high throughput screening identified phosphorylation sites downstream of Cdk5. These phosphorylation events serve as biomarkers and effectively pinpoint Cdk5-driven tumors. Toward achieving targeted therapy, we demonstrate that mouse models of neuroendocrine cancer are responsive to selective Cdk5 inhibitors and biomimetic nanoparticles are effective vehicles for enhanced tumor targeting and reduction of drug toxicity. Finally, we show that biomarkers of Cdk5-dependent tumors effectively predict response to anti-Cdk5 therapy in patient-derived xenografts. Thus, a phosphoprotein-based diagnostic assay combined with Cdk5-targeted therapy is a rational treatment approach for neuroendocrine malignancies.

Decreasing Trends in Road Traffic Injury Incidence and Mortality in Nigeria: A Ten-Year Analysis.

BACKGROUND: Road traffic accidents constitute a significant public health burden in Nigeria. In this study, we aim to (1) characterize the temporal burden of road traffic injury (RTI) and mortality rates in Nigeria over a decade, (2) identify regional RTI incidence, mortality trends, and high-risk regions, and (3) assess the impact of state population on injury and mortality. MATERIALS AND METHODS: We retrospectively reviewed aggregate state-level RTI incidence and mortality counts reported by the Federal Road Safety Corps from January 2001 through December 2010. We also reviewed population data from the National Population Commission. In addition to national analyses, regional analyses were performed in Nigeria's six geopolitical zones and one Federal Capital Territory (FCT). Regression analysis was also performed to determine the relationship between population and RTI incidence and mortality. RESULTS: The national median RTI incidence and mortality rates declined by 53% and 75%, respectively, between 2001 and 2010. Analysis by geopolitical zone yielded the greatest increases for both injury and mortality in the FCT and the greatest decreases for both in the South-South region. The average geopolitical zone, apart from the FCT, experienced a 24% decrease in the incidence rate and a 69% decrease in the mortality rate. An analysis of variance, run to assess potential differences in RTI incidence and mortality rates by state population, yielded significant values of P = 0.0023 for injury and P = 0.0002 for mortality. CONCLUSIONS: Acknowledging the potential for underreporting, a more holistic surveillance approach would generate more accurate data for future policy creation to improve clinical outcomes.

When policy meets the pedal: A reduction in motorcyclist fatalities following the implementation of a road traffic law in Lagos, Nigeria.

Objective: The Lagos State Road Traffic Law of 2012 sought to curb reckless okada use and the objective of this study is to determine its impact on motorcyclist fatalities in Nigeria's most densely populated state. This is the first study to date that analyzes the potential impact of the Law on motorcyclist fatalities across Lagos State.Methods: We retrospectively reviewed monthly motorcyclist fatalities in Lagos between January 2012 and December 2015. We analyzed the data using Geographic Information Systems (GIS) software, and used Quantum GIS ver. 2.16.2 to create maps illustrating the spatial-epidemiological distribution of motorcyclist fatalities across Lagos' health facilities. The data was collated into three eight-month periods for analysis (pre-intervention, immediate post-intervention, and sustained post-intervention). Period 1 was January to August 2012, Period 2 was September 2012 to April 2013, and Period 3 was May to December 2013. The data were compared in SPSS using the Welch's ANOVA and Tanhame (post-hoc) tests with a 5% significance level.Results: Motorcyclist fatalities in Lagos fell by an average of 76% over the study period. Over 55% of the fatalities were recorded in five health facilities, located in an area of high road network density. The number of newly registered motorcycles also declined by an average of 69%. The Welch's ANOVA yielded a statistically significant difference between the Periods' means (p < 0.0001). The Tamhane post-hoc test showed significant differences in the mean decrease in fatalities between Period 1 and Period 2 (p = 0.002), and Period 1 and Period 3 (p < 0.0001).Conclusions: This study shows a significant decline in motorcyclist fatalities following the implementation of the Lagos State Road Traffic Law of 2012. A more comprehensive approach to data collection along with an updated law could contribute towards a sustainable reduction of motorcyclist mortality.

Neurologic injuries following road traffic accidents in the Dominican Republic: Examining causes and potential solutions.

Objective: Road traffic accidents (RTAs) are the number one cause of traumatic brain injuries (TBIs) worldwide. This study examines RTA-related TBIs in the Dominican Republic, a country in the Caribbean with the highest RTA fatality rate in the Western Hemisphere. Methods: We interviewed 117 adult patients or medical guardians of patients admitted to Hospital Traumatológico Dr. Ney Arias Lora in Santo Domingo following an RTA. Information regarding the type of accident, patient demographics, and injuries sustained was collected for each patient. Results: Most study participants were males (79.5%), and the most common method of transportation was motorized 2-wheeled vehicle (MTW; 74.4%). Of the 69 patients who suffered a TBI, 66.7% were classified as moderate-severe TBIs and 30.3% were classified as mild TBIs. The most common types of intracranial hemorrhage were subdural hemorrhage (12%) and subarachnoid hemorrhage (9.4%). Helmet use among admitted MTW riders was reported at 22.4%, and none of the 9 MTW riders who died in the hospital were wearing a helmet. Only 58.1% of patients lived in an area that offered 911 emergency response services at the time of the study. At 66.2%, the majority of people living within the 911 service area utilized emergency response services following an RTA. Multiple logistic regression determined that the utilization of 911 emergency response services was associated with a decrease in the likelihood of presenting with a moderate/severe TBI by a factor of 0.78 (adjusted odds ratio [OR]; P < .008; 95% confidence interval [CI], 0.65, 0.93). Nonuse of a helmet was associated with a 1.22 times increased risk of presenting with a moderate/severe TBI (adjusted OR; P < .04; 95% CI, 1.01, 1.61). Age and gender were not statistically significant in this model. Conclusions: The results of this study support 2 important avenues for reducing the burden of RTA-associated neurologic disease in the Dominican Republic. As with many other middle-income countries, MTWs represent an economical and efficient mode of transportation. Therefore, increasing helmet use may be the most effective way to reduce RTA-associated TBIs. In addition, continuing the expansion of postcrash emergency response services may mitigate the severity of RTA-associated neurologic disease.

Rapid Relief: Thyroidectomy is a Quicker Cure than Radioactive Iodine Ablation (RAI) in Patients with Hyperthyroidism.

BACKGROUND: Time to hormonal control after definitive management of hyperthyroidism is unknown but may influence patient and physician decision making when choosing between treatment options. The hypothesis is that the euthyroid state is achieved faster after thyroidectomy than RAI ablation. METHODS: A retrospective review of all patients undergoing definitive therapy for hyperthyroidism was performed. Outcomes after thyroidectomy were compared to RAI. RESULTS: Over 3 years, 217 patients underwent definitive therapy for hyperthyroidism at a county hospital: 121 patients received RAI, and 96 patients underwent thyroidectomy. Age was equivalent (p = 0.72). More males underwent RAI (25% vs 15%, p = 0.05). Endocrinologists referred for both treatments equally (p = 0.82). Both treatments were offered after a minimum 1-year trial of medical management (p = 0.15). RAI patients mostly had Graves (93%), versus 73% of thyroidectomy patients (p < 0.001). Thyroidectomy patients more frequently had eye symptoms (35% vs 13%, p < 0.001), compressive symptoms (74% vs 15%, p < 0.001), or were pregnant/nursing (14% vs 0, p < 0.001). While the thyroidectomy patients had a documented discussion of all treatment modalities, 79% of RAI patients did not have a documented discussion regarding the option of surgical management (p < 0.001). Both treatment groups achieved an euthyroid state (71% vs 65%, p = 0.39). Thyroidectomy patients became euthyroid faster [3 months (2-7 months) versus 9 months (4-14 months); p < 0.001]. CONCLUSIONS: Thyroidectomy for hyperthyroidism renders a patient to an euthyroid state faster than RAI. This finding may be important for patients and clinicians considering definitive options for hyperthyroidism.

Epidemiologic shifts for burn injury in Ethiopia from 2001 to 2016: Implications for public health measures.

BACKGROUND: The last generation has seen Ethiopia, a low income country with a population of 100 million people, undergo a marked increase in urbanization and development. The effects of these demographic changes on the epidemiology of burn risk and thermal injury in Ethiopia are unknown. This gap constitutes a major barrier to the creation of effective burn prevention programs. METHODS: Yekatit 12 Hospital in Addis Ababa is the only burn unit in Ethiopia. In this cross sectional retrospective study, we identified and reviewed all admissions due to burn injury at that facility between 1/1/2016 and 12/31/2016. We then compared them to a previously published burn cohort treated at the same facility between 7/1/2001 and 9/31/2002. Chi square was used to compare proportions between the two samples. Continuous covariates are reported as descriptive data due to missing variance data in the 2001-02 publication. RESULTS: There were a total of 121 subjects in the 2001-02 sample and 176 subjects in the 2016 sample. The 2016 sample was found to have a significantly larger proportion of males (57%) as compared to the 2001-02 sample (36%) (p=0.0003) and a significantly higher proportion of electrical injuries (27%) than the previous cohort (5%) (p<0.0001). No significant differences were seen in mortality rates between the 2016 and 2001-02 cohorts (8% vs 12%, respectively, p=0.29) or in the regions of origin (44% outside Addis Ababa vs 54%, p=0.09) For the 2016 sample, the highest surviving Baux score was 76 while the mean Baux score for survivors was 29.6±20.11. CONCLUSION: As Ethiopia has become more industrialized over the last 15 years, the demographic pattern of burn injury has changed accordingly as electrical injuries have increased five-fold with males now constituting a majority of burn cases.

Early endocrine attending surgeon presence increases operating room efficiency.

BACKGROUND: Preincision operating room (OR) preparation varies greatly. Cases requiring exacting preoperative setup may be more sensitive to inconsistent team members and trainees. Leadership and oversight by the surgeon may facilitate a timely start. The study hypothesized that early attending presence in the OR expedites surgery start time, improving efficiency, and decreasing cost. METHODS: Prospective data collection of endocrine surgery cases at an urban teaching hospital was performed. Time points recorded in minutes. Cost/min of OR time was $54. Patients classified as in the OR ≤10 min before attending arrival or >10 min before attending arrival. RESULTS: A total of 227 cases (166 thyroid, 54 parathyroid, 10 adrenal) were performed over 14 mo. Of the patients, 128 were in the OR ≤10 min before attending arrival, and 99 patients were >10 min (3 ± 3 min versus 35 ± 14 min, P < 0.01). The ≤10 min procedures started sooner after patient arrival in OR (40 ± 11 versus 63 ± 19, P < 0.01) which equated to $1202 of savings before incision. Although attending time in the OR before incision was equivalent between groups for adrenal and parathyroid, time to incision was shorter in the ≤10 min groups, saving $2416 ± 477 and $1458 ± 244, respectively (P < 0.01). Attending time in OR before thyroidectomy was 13 min longer in ≤10 min than >10 min (P < 0.01), but incisions were made 20 min sooner (P < 0.01) equating to $1076 ± 120 in savings. CONCLUSIONS: Early attending presence in the OR shortens time to incision. For parathyroid and adrenal cases, this does not require additional surgeon time. In ORs without consistent teams, early attending presence in the OR improves efficiency and yields significant cost savings.

Contralateral adrenal abnormalities in Conn's syndrome.

BACKGROUND: During the course of evaluation for primary hyperaldosteronism, cross-sectional imaging is obtained in efforts to identify patients with an aldosterone producing adenoma (APA). A subset of these patients will have a synchronous, contralateral adrenal abnormality. Adrenal vein sampling (AVS) further guides clinical decision making by identifying unilateral (APA) versus bilateral hypersecretion. In the subset of patients with contralateral adrenal abnormalities, it is unclear how this affects the durability of an adrenalectomy for APA. This study characterizes this group of patients to assess the efficacy of surgical intervention. METHODS: A retrospective review of patients undergoing adrenalectomy for APA based on AVS at a university practice. Preoperative and postoperative patient characteristics, laboratory evaluations, imaging results, and final pathology were noted. RESULTS: From 2000 to 2011, 103 patients with APA underwent unilateral adrenalectomy. Eighteen patients (17%) had discordant results between AVS and imaging. Most of these patients were male (78%), and the mean age was 57 ± 13 y. Median duration of follow-up was 3.5 y [1 y, 6 y]. All patients with initial hypokalemia were rendered normokalemic after the operation. Four patients increased their antihypertensive regimen during the follow-up period. These patients all had nodular hyperplasia on final pathology. CONCLUSIONS: In patients with bilateral adrenal abnormalities who have undergone unilateral adrenalectomy for primary hyperaldosteronism, patients with clear APAs on final pathology appear to have durable outcomes after resection. Conversely, nodular hyperplasia on final pathology may be a risk factor for ongoing aldosterone hypersecretion. An algorithm for biochemical surveillance in this subset of patients should be considered.

Differential expression of cell cycle regulators in CDK5-dependent medullary thyroid carcinoma tumorigenesis.

Medullary thyroid carcinoma (MTC) is a neuroendocrine cancer of thyroid C-cells, for which few treatment options are available. We have recently reported a role for cyclin-dependent kinase 5 (CDK5) in MTC pathogenesis. We have generated a mouse model, in which MTC proliferation is induced upon conditional overexpression of the CDK5 activator, p25, in C-cells, and arrested by interrupting p25 overexpression. Here, we identify genes and proteins that are differentially expressed in proliferating versus arrested benign mouse MTC. We find that downstream target genes of the tumor suppressor, retinoblastoma protein, including genes encoding cell cycle regulators such as CDKs, cyclins and CDK inhibitors, are significantly upregulated in malignant mouse tumors in a CDK5-dependent manner. Reducing CDK5 activity in human MTC cells down-regulated these cell cycle regulators suggesting that CDK5 activity is critical for cell cycle progression and MTC proliferation. Finally, the same set of cell cycle proteins was consistently overexpressed in human sporadic MTC but not in hereditary MTC. Together these findings suggest that aberrant CDK5 activity precedes cell cycle initiation and thus may function as a tumor-promoting factor facilitating cell cycle protein expression in MTC. Targeting aberrant CDK5 or its downstream effectors may be a strategy to halt MTC tumorigenesis.

The impact of obesity on the presentation of primary hyperparathyroidism.

CONTEXT: Obesity has been associated with elevated serum PTH (sPTH) in the general population. Obesity may also alter the clinical presentation in patients with primary hyperparathyroidism (PHPT). OBJECTIVES: The objectives of the study were to compare the clinical presentation of obese (OB) vs nonobese (NO) PHPT patients and to assess the impact of obesity on the presentation of PHPT independent of serum calcium and PTH. PATIENTS: Consecutive PHPT patients who underwent parathyroidectomy between 2003 and 2012 by a single surgical group participated in the study. SETTING: The study was conducted at an academic medical center. DESIGN: Cross-sectional review of records of preoperative demographic, historical, laboratory, and densitometry findings and intraoperative pathological findings were compared in OB vs NO patients. MAIN OUTCOME MEASURES: The prevalence of nephrolithiasis and osteoporosis was measured. RESULTS: Two hundred forty-seven PHPT patients were included in this analysis. Fifty percent were OB and 79% were women. Mean body mass index was 25.3 ± 3.3 and 36.0 ± 5.2 kg/m(2) in the NO and OB groups, respectively. Age, gender, and race distribution was similar between the two groups. Serum calcium was similar between the groups (11.0 ± 0.7 mg/dL in NO vs 11.1 ± 0.9 mg/dL in OB, P = .13), whereas sPTH was higher in OB (151 ± 70 vs 136 ± 69 pg/mL, P = .03). The OB group exhibited higher prevalence of hypercalciuria (urine calcium > 400 mg per 24 h) (41% vs 23% in NO, P = .01) and nephrolithiasis (36% vs 21% in NO, P = .03). Despite higher sPTH, OB patients showed higher bone mineral density and a lower rate of osteoporosis (21% vs 35%, P = .05). Differences in the prevalence of hypercalciuria and osteoporosis between the groups persisted after adjustment for age, race, estimated glomerular filtration rate, gender, sPTH, and calcium. CONCLUSIONS: In PHPT patients, obesity is a risk factor for hypercalciuria and nephrolithiasis and is protective against osteoporosis. The impact of parathyroidectomy on the clinical features of obese PHPT patients merits further evaluation.