Surgical challenges of giant parathyroid adenomas weighing 10 g or more

PURPOSE

An average parathyroid adenoma (PA) weighs < 1 g. This study aimed to characterise giant PAs ≥ 10 g (GPAs) to facilitate surgical management of primary hyperparathyroidism (PHPT).

METHODS

All patients with a GPA confirmed on histology were recruited from the Monash University Endocrine Surgery Unit database. Clinical and demographic data were collected and compared to a group of non-GPA patients.

RESULTS

A total of 14 GPAs were identified between 2007 and 2018 out of 863 patients (1.6%) with a single PA excised for PHPT. The GPA patients were compared to a control group of 849 non-GPA patients in the same period with similar mean age (62 ± 16 vs 63 ± 14, P = 0.66) and gender distribution (64% vs 75% female, P = 0.35). Pre-operative calcium (Ca) and parathyroid hormone (PTH) levels were significantly higher in GPA patients (P < 0.001). A higher percentage of GPA patients (79%) had concordant localisation studies (ultrasound and sestamibi) than control patients (59%), (P = 0.13), but they were significantly less likely to undergo MIP (55% vs 82%, P = 0.02). The median GPA weighed 12.5 g (IQR 10.5-24.3). Median serum Ca normalised by day 1 post-operatively, while PTH remained elevated. Both serum Ca and PTH levels were in the normal range at 3 months. All GPA lesions were benign on histopathology.

CONCLUSION

GPAs are rare and display severe clinical and biochemical abnormalities. Despite their large size, concordant pre-operative imaging was not always achieved, and a few patients were suitable for MIP.

Family Perceptions and Provision of Analgesia for Acutely Painful Conditions in Children: A Multi-Centred Prospective Survey

BACKGROUND: More than two-thirds of children who present to the emergency department (ED) complain of pain. It is well known that children’s pain is poorly managed in the ED compared to their adult counterparts. With respect to analgesic administration in the ED, discrepancies exist between physician self-report and institutional audit. Patient refusal of analgesia is a likely explanation. There is good evidence that misconceptions and fears about analgesia in children are common among caregivers and may contribute to withholding pain medication. To date, no study has surveyed caregivers presenting the the ED to assess frequency of analgesic administration and reasons for withholding analgesia. We hypothesize that there will be a significant proportion of care-givers and patients that refuse pain medication in the ED. We also hypothesize that there will be a wide range of reasons for refusal. The insight we gain from this study will help nurses, clinical educators, and physicians provide the appropriate information to parents in an effort to target misconceptions and allay fears.

OBJECTIVES: Our objectives were to characterize the degree of care-giver and patient provision of analgesia prior to arrival, refusal of analgesia in the ED, and reasons behind their decision-making process. We hope to identify specific misconceptions, attitudes, or beliefs that impair the optimal provision of analgesia to children in the ED.

DESIGN/METHODS: A novel survey was designed by a focus group using an iterative approach and implemented over a 16-week period across two Canadian tertiary care paediatric EDs. We included a consecutive sample of caregivers of children aged 4-17 years with an acutely painful condition (headache, abdominal pain, injury, otitis, pharyngitis). Caregivers were asked to answer questions covering five domains: (i) demographics, (ii) analgesia prior to arrival (iii) analgesia offered in the ED and reasons for refusal, (iv) perceptions of analgesia, and (v) caregiver satisfaction at discharge. Children were asked to rate their pain on arrival and at discharge. The primary outcome was the frequency of caregiver provision of analgesia prior to arrival and the proportion of caregivers who accept the offer of analgesia offered in the ED.

RESULTS: Three hundred forty-four caregivers completed the survey. The majority were female (269/339, 79%), aged 36 years or older (256/340, 75%) with a post-secondary education (237/336, 71%). Most (309/339, 91%) reported being able to “tell when their child was in pain”. All respondents rated their child’s maximal pain related to the presenting condition as at least a 6/10. With regards to the primary outcome, 229/338 (68%) of caregivers reported that they did not treat their child’s pain prior to arrival in the ED. Of those who did treat their child’s pain, ibuprofen was the most commonly used analgesic (77/112, 69%). The most common reasons for withholding analgesia was a lack of time (80/210, 38%), fear of masking seriousness of child’s condition (49/210, 23%), fear of masking signs and symptoms (48/210, 23%), and a lack of analgesia at home (47/210, 22%). Analgesia was offered to 186/344 (45%) of children in the ED and the majority of caregivers 157/186 (84%) accepted the offer. The most common reason for not accepting analgesia in the ED was child refusal (15/20, 75%). Most, 231/338 (68%) of caregivers felt that their child’s pain was managed well in the ED.

CONCLUSION: This survey of caregiver perceptions surrounding analgesia for children with acutely painful conditions presenting to the pae-diatric ED suggests that most do not treat their child’s pain prior to arrival, despite high levels of pain. Misconceptions surrounding analgesia prior to arrival are common. Despite this, most caregivers accepted analgesia in the ED. Our results suggest that educational strategies should be directed at caregiver awareness of the impact of pain on children and the need for prompt analgesic therapy, even when an ED visit is planned.

Removal of sub-mucosal foreign body (metal wire) from the pharynx using image intensifier

It is well known how difficult it is to localize a foreign body in the sub-mucosal tissues. This is a report of a male who swallowed a metal wire which lodged in the pharyngeal sub-mucosal tissue. The foreign body was localized using an image intensifier and removed successfully.

Comparison of diagnostic accuracy between USG and MRCP in biliary and pancreatic pathology

OBJECTIVE :- To evaluate the diagnostic accuracy between USG & MRCP in the patients suspected of biliary and pancreatic pathology. MATERIAL & METHODS : Fifty patients attending the hospital of all age groups and both sexes, suspected of biliary and pancreatic pathology, were examined first by USG and followed by MRCP, and findings were correlated with ERCP and biopsy report. RESULTS :- Out of 50 patients 38 patients had biliary pathology and 12 patients had pancreatic pathology. Out of this, MRCP was 98 % accurate in diagnosis when results were compared in all cases. USG didn′t help in case of CBD stricture, in evaluating Pancreatic duct into Chronic pancreatitis and in lower end of CBD pathology. CONCLUSION :- USG is the cheap and easily available modality so, it is the primary investigative modality for suspected patients of biliary and pancreatic pathology, but MRCP has high diagnostic value.

Spherical foreign bodies in the oesophagus removed by balloon angiographic catheter

Two children aged three and seven years presented to the department of Otolaryngology with total dysphagia following the accidental swallowing of a steel ball bearing and a plastic ball. These rare spherical foreign bodies were removed successfully by oesophagoscopy under general anaesthesia using an innovative method involving a balloon angiographic catheter.