457 The Effect of Biochemical Adversity of Primary Hyperparathyroidism on Preoperative Imaging (SPECT-CT and US Parathyroids)

Aim

Primary hyperparathyroidism (PHPT) is a common endocrine disorder, with an estimated incidence of 1/500 women and 1/2000 men older than 40 years. Several factors influence the positivity of preoperative scans including serum calcium, PTH and vitamin D levels, and gland size. The aim of our study is to examine the effect of biochemical adversity of primary hyperparathyroidism on preoperative imaging (SPECT-CT and US parathyroids).

Method

Retrospective study of 176 parathyroidectomies (2017-2020) in a tertiary referral centre with biochemistry, SPECT-CT, US parathyroids and histology outcomes being recorded. Failed parathyroidectomies were excluded.

Results

Patients were divided into 4 groups based on the preoperative calcium levels (normocalcemia <2.6, 3.4%; mild 2.60-2.79, 51.1%; moderate 2.80-2.99, 31.2%; severe >3.0 mmol/l, 14.2% of patients). Age (p-0.0297), preoperative vitamin D (p-0.03) and PTH levels (p-0.0001) were different while SPECT-CT positivity (p-0.29) weight of gland (p-0.015) and US positivity (p-0.09) were similar within the subgroups. Looking at the whole group, patients with positive SPECT-CT have a larger weight (p < 0.0001) while preoperative PTH levels was higher for the positive SPECT-CT patients (p-0.0289). No relation was identified between calcium levels and SPECT-CT positivity (p-0.18). No significance between preoperative vitamin D and positivity of US and SPECT-CT within the study group were noted.

Conclusions

Serum PTH levels and weight of the gland are directly correlated with positivity of preoperative imaging. Preoperative calcium and vitamin D levels correlates indirectly with the severity of the disease but did not influence the preoperative imaging positivity.

Correlation between biochemical features and outcomes of preoperative imaging (SPECT-CT and Ultrasound) in primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism is the third most common endocrine disorder, diagnosed by elevated parathyroid hormone (PTH) in hypercalcaemia. Several biochemical factors have been described to suggest severity of disease and may be correlated with preoperative imaging.

METHODS

This was a retrospective study of patients who underwent parathyroidectomy over a 3-year period. Preoperative calcium, PTH, vitamin D levels, ALP (alkaline phosphatase), vitamin D, serum phosphate and US and SPECT-CT positivity was noted.

RESULTS

176 patients underwent parathyroidectomy and these were divided into 4 groups based on preoperative calcium. Overall, 61% of patients showed concordance between imaging and operative findings. Severe hypercalcaemia was associated with higher PTH levels, lower vitamin D levels, an increased rate of abnormal ALP levels, lower phosphate, male gender and highest rate of imaging concordance. Imaging positivity was associated with severe hypercalcaemia and elevated PTH levels. Level of PTH >125 pmol/L and hypercalcaemia >2.8 mmol/L are the most accurate cut-off levels for scan positivity.

CONCLUSION

Biochemical factors associated with severity of the disease are directly correlated with positivity of preoperative imaging while ALP and vitamin D did not influence the preoperative imaging positivity but are associated with disease adversity. Serum phosphate level independently predicted results of parathyroid US.

Changing pattern of pheochromocytoma and paraganglioma in a stable UK population

Context

Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern.

Objective

The aim was to further characterize PCC/PGLs in a stable population.

Methods

A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted.

Results

86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4-120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178).

Conclusion

Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Consistent and reproducible staining of glia by a modified Golgi-Cox method

BACKGROUND

Golgi-Cox staining is a powerful histochemical approach which has been used extensively to visualize the morphology of neurons and glia. However, its usage as a first-choice method is hindered by its uncertain nature, diminished consistency and lengthy staining duration. The FD Rapid GolgiStain™ Kit (FD Neurotechnologies, Inc., USA) has been developed by employing the Golgi-Cox approach. It is a simple, reliable and reproducible way of performing Golgi impregnation for the analysis of neuronal morphology.

NEW METHOD

We report here simple modifications to the manufacturer's protocol which enable reproducible and reliable staining of glial cells.

RESULTS

Exposure of brain tissue to 4% paraformaldehyde (PFA) during perfusion followed by postfixation with 8% glutaraldehyde in 4% PFA led to only glial cells being stained, whereas in the absence of postfixation both neurons and glia were stained with unclear morphology. Additionally, we found that impregnation at 26°C±1 was critical to attain uniform staining.

COMPARISON WITH EXISTING METHOD

Our modified Golgi-Cox approach is consistent and reproducible and affords uniform glial staining throughout the brain.

CONCLUSION

As this protocol stains only a small percentage of cells, it is suitable for the analysis of individual cells.

Comparing ascitic aspirate and tissue biopsy in the diagnosis of ovarian malignancy

The objective of this retrospective study was to assess the role of tissue biopsy in ovarian cancer where a diagnosis had been made from cytological assessment of ascites. A total of 63 women had been coded for ovarian carcinoma during the period; 48 had undergone cytological or histological investigation, of which six had undergone tissue biopsy, despite having had a cytological diagnosis. In all six cases (100%), the tissue biopsy concurred with the original diagnosis. We conclude that, where a clinically- and radiologically-correlated cytological diagnosis is made, the benefits of an invasive procedure to obtain tissue samples do not outweigh the risks to the patient.

Diagnostic scanning for suspected scaphoid fractures: an economic evaluation based on cost-minimisation models

OBJECTIVE

To compare, the costs of diagnosing suspected scaphoid fractures using various protocols with various scanning techniques.

DESIGN

Analysis of the cost-minimisation models. The models were prepared after an audit of the existing protocol for suspected scaphoid fractures.

SETTING

Departments of Accident and Emergency and Orthopaedics, Leighton General Hospital, Crew, Cheshire, UK.

SUBJECTS

A total of 124 patients presenting to A&E with suspected scaphoid fractures between 1 December 1999 and 1 May 2000.

MAIN OUTCOME MEASURES

Costs to the hospital budget in ruling out or diagnosing scaphoid fractures in these patients.

RESULTS

The cost using an existing protocol that does not routinely involve scanning was pounds 15,554. Projected costs for many (but not all) of the alternative protocols involving routine use of scanning procedures were found to be lower or comparable.

CONCLUSIONS

Protocols based on diagnostic scanning for suspected scaphoid fractures can be comparable to a protocol which does not rely on scanning techniques because they can avoid repeated radiographs, clinical appointments and plaster cast changes. However, any such protocol must be tailored on the basis of the workload, and the availability of resources.