Black patients are more likely to undergo parathyroidectomy for secondary hyperparathyroidism

BackgroundPrior studies have demonstrated racial disparities in the severity of secondary hyperparathyroidism among dialysis patients. Our primary objective was to study the racial and socioeconomic differences in the timing and likelihood of parathyroidectomy in patients with secondary hyperparathyroidism.MethodsWe used the United States Renal Data System to identify 634,428 adult (age ≥18) patients who were on maintenance dialysis between 2006 and 2016 with Medicare as their primary payor. Adjusted multivariable Cox regression was performed to quantify the differences in parathyroidectomy by race.ResultsOf this cohort, 27.3% (173,267) were of Black race. Compared to 15.4% of White patients, 23.1% of Black patients lived in a neighborhood that was below a predefined poverty level (P < .001). The cumulative incidence of parathyroidectomy at 10 years after dialysis initiation was 8.8% among Black patients compared to 4.3% among White patients (P < .001). On univariable analysis, Black patients were more likely to undergo parathyroidectomy (adjusted hazard ratio = 1.83; 95% confidence interval, 1.74–1.93). This association persisted after adjusting for age, sex, cause of end-stage renal disease, body mass index, comorbidities, dialysis modality, and poverty level (adjusted hazard ratio = 1.35; 95% confidence interval, 1.27–1.43). Therefore, patient characteristics and socioeconomic status explained 26% of the association between race and likelihood of parathyroidectomy.ConclusionBlack patients with secondary hyperparathyroidism due to end-stage renal disease are more likely to undergo parathyroidectomy with shorter intervals between dialysis initiation and parathyroidectomy. This association is only partially explained by patient characteristics and socioeconomic factors.     

Optimal extent of initial parathyroid resection in patients with multiple endocrine neoplasia syndrome type 1: A meta-analysis

BackgroundHyperparathyroidism is an almost universal feature of multiple endocrine neoplasia type 1 syndrome. We present a systematic review and meta-analysis of the postoperative outcomes of patients undergoing initial operative treatment of primary hyperparathyroidism complicating multiple endocrine neoplasia 1.MethodsA comprehensive literature search was performed with a priori defined exclusion criteria for studies comparing total parathyroidectomy, subtotal parathyroidectomy, and less than subtotal parathyroidectomy.ResultsTwenty-one studies incorporating 1,131 patients (272 undergoing total parathyroidectomy, 510 subtotal parathyroidectomy, and 349 less than subtotal parathyroidectomy) were identified. Pooled results revealed increased risk for long-term hypoparathyroidism in total parathyroidectomy patients (relative risk 1.61; 95% confidence interval, 1.12?2.31; P = .009) versus those undergoing subtotal parathyroidectomy. In the less than subtotal parathyroidectomy or subtotal parathyroidectomy comparison group, a greater risk for recurrence of hyperparathyroidism (relative risk 1.37; 95% confidence interval, 1.05?1.79; P = .02), persistence of hyperparathyroidism (relative risk 2.26; 95% confidence interval, 1.49?3.41; P = .0001), and reoperation for hyperparathyroidism (relative risk 2.48; 95% confidence interval, 1.65?3.73; P < .0001) was noted for less than subtotal parathyroidectomy patients, albeit with lesser risk for long-term for hypoparathyroidism (relative risk 0.47; 95% confidence interval, 0.29?0.75; P = .002).ConclusionSubtotal parathyroidectomy compares favorably to total parathyroidectomy, exhibiting similar recurrence and persistence rates with a decreased propensity for long-term postoperative hypoparathyroidism. The benefit of the decreased risk of hypoparathyroidism in less than subtotal parathyroidectomy is negated by the increase in the risk for recurrence, persistence, and reoperation. Future studies evaluating the performance of less than subtotal parathyroidectomy in specific multiple endocrine neoplasia 1 phenotypes should be pursued in an effort to delineate a patient-tailored, operative approach that optimizes long-term outcomes.     

Incidental parathyroidectomy in thyroidectomy and central neck dissection

BackgroundAlthough higher thyroidectomy volume has been linked with lower complication rates, its association with incidental parathyroidectomy remains less studied. The volume relationship is even less clear for central neck dissection, where individual parathyroid glands are at greater risk.MethodsPatients undergoing thyroidectomy with or without central neck dissection were evaluated for incidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Univariate and multivariable analyses were performed using binary logistic regression.ResultsOverall, 1,114 thyroidectomies and 396 concurrent central neck dissections were performed across 7 surgeons. Incidental parathyroidectomy occurred in 22.4% of surgeries (range, 16.9%–43.6%), affecting 7.1% of parathyroids at risk (range, 5.8%–14.5%). When stratified by surgeon, lower incidental parathyroidectomy rates were associated with higher thyroidectomy volumes (R² = 0.77, P = .008) and higher central neck dissection volumes (R² = 0.93, P < .001). On multivariable analysis, low-volume surgeon (odds ratio 2.94, 95% confidence interval 2.06–4.19, P < .001), extrathyroidal extension (odds ratio 3.13, 95% confidence interval 1.24–7.87, P = .016), prophylactic central neck dissection (odds ratio 2.68, 95% confidence interval 1.65–4.35, P <.001), and therapeutic central neck dissection (odds ratio 4.44, 95% confidence interval 1.98–9.96, P < .001) were the most significant factors associated with incidental parathyroidectomy. In addition, incidental parathyroidectomy was associated with a higher likelihood of temporary hypoparathyroidism (odds ratio 2.79, 95% confidence interval 1.45–5.38, P = .002) and permanent hypoparathyroidism (odds ratio 4.62, 95% confidence interval 1.41–5.96, P = .025), but not permanent hypocalcemia (odds ratio 1.27, 95% confidence interval 0.48–3.35, P = .63). Higher lymph node yield in central neck dissection was not associated with higher incidental parathyroidectomy rates (odds ratio 1.13, 95% confidence interval 0.85–8.81, P = .82).ConclusionHigher surgical volume conferred a lower rate of incidental parathyroidectomy. Nonetheless, greater lymph node yield in central neck dissections did not result in greater parathyroid-related morbidity. Such findings support the value of leveraging surgical volume to both optimize oncologic resection and minimize complication rates.     

A postdischarge venous thromboembolism risk calculator for inflammatory bowel disease surgery

BackgroundGuidelines recommend extended chemoprophylaxis for venous thromboembolism in high-risk patients having operations for inflammatory bowel disease. Quantifying patients' risk of venous thromboembolism, however, remains challenging. We sought (1) to identify factors associated with postdischarge venous thromboembolism in patients undergoing colorectal resection for inflammatory bowel disease and (2) to develop a postdischarge venous thromboembolism risk calculator to guide prescribing of extended chemoprophylaxis.MethodsPatients who underwent an operation for inflammatory bowel disease from 2012 to 2018 were identified from the American College of Surgeons National Surgical Quality Improvement Program for colectomy and proctectomy procedure targeted modules. Postdischarge venous thromboembolism included pulmonary embolism or deep vein thrombosis diagnosed after discharge from the index hospitalization. Multivariable logistic regression estimated the association of patient/operative factors with postdischarge venous thromboembolism. A postdischarge venous thromboembolism risk calculator was subsequently constructed.ResultsOf 18,990 patients, 199 (1.1%) developed a postdischarge venous thromboembolism within the first 30 postoperative days. Preoperative factors associated with postdischarge venous thromboembolism included body mass index (1.9% with body mass index ≥35 vs 0.8% with body mass index 18.5–24.9; odds ratio 2.34 [95% confidence interval 1.49–3.67]), steroid use (1.3% vs 0.7%; odds ratio 1.91 [95% confidence interval 1.37–2.66]), and ulcerative colitis (1.5% vs 0.8% with Crohn’s disease; odds ratio 1.76 [95% confidence interval 1.32–2.34]). Minimally invasive surgery was associated with postdischarge venous thromboembolism (1.2% vs 0.9% with open; odds ratio 1.42 [95% confidence interval 1.05–1.92]), as was anastomotic leak (2.8% vs 1.0%; odds ratio 2.24 [95% confidence interval 1.31–3.83]) and ileus (2.1% vs 0.9%; odds ratio 2.60 [95% confidence interval 1.91–3.54]). The predicted probability of postdischarge venous thromboembolism ranged from 0.2% to 14.3% based on individual risk factors.ConclusionPreoperative, intraoperative, and postoperative factors are associated with postdischarge venous thromboembolism after an operation for inflammatory bowel disease. A postdischarge venous thromboembolism risk calculator was developed which can be used to tailor extended venous thromboembolism chemoprophylaxis by individual risk.     

Phenotypes of primary hyperparathyroidism: Does parathyroidectomy improve clinical outcomes for all?

BackgroundPrimary hyperparathyroidism consists of 3 biochemical phenotypes: classic, normocalcemic, and normohormonal primary hyperparathyroidism. The clinical outcomes of patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism are not well described.MethodA retrospective review of patients who underwent parathyroidectomy at a single institution was performed. A logistical regression analysis of postoperative nephrolithiasis and highest percentage change in dual-energy x-ray absorptiometry scan comparison using Kruskal-Wallis test and Cox proportional hazard analysis of recurrence-free survival were performed.ResultsA total of 421 patients were included (340 classic, 39 normocalcemic primary hyperparathyroidism, 42 normohormonal primary hyperparathyroidism). Median follow-up was 8.8 months (range 0–126). Higher rates of multigland disease were seen in normocalcemic primary hyperparathyroidism (64.1%) and normohormonal primary hyperparathyroidism (56.1%) compared to the classic (25.8%), P < .001. There were no differences in postoperative complications. The largest percentage increases in bone mineral density at the first postoperative dual-energy x-ray absorptiometry scan were higher for classic (mean ± SD, 6.4 ± 9.1) and normocalcemic primary hyperparathyroidism (4.8 ± 11.9) compared to normohormonal primary hyperparathyroidism, which remained stable (0.2 ± 14.2). Normocalcemic primary hyperparathyroidism were more likely to experience nephrolithiasis postoperatively, 6/13 (46.2%) compared to 11/68 (16.2%) classic, and 2/13 (15.4%) normohormonal primary hyperparathyroidism, P = .0429. Normocalcemic primary hyperparathyroidism was the only univariate predictor of postoperative nephrolithiasis recurrence (odds ratio [95% confidence interval] 4.44 [1.25–15.77], P = .029). Normocalcemic primary hyperparathyroidism was significantly associated with persistent disease with 6/32 (18.8%) compared to 1/36 (2.8%) and 3/252 (1.2%) in normohormonal primary hyperparathyroidism and classic (P < .001).ConclusionThree phenotypes of primary hyperparathyroidism are distinct clinical entities. Normocalcemic primary hyperparathyroidism had higher incidence of persistent disease and postoperative nephrolithiasis but demonstrated improvements in postoperative bone density. These data should inform preoperative discussions with patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism regarding postoperative expectations.     

Sentinel lymph node biopsy in women over 70: Evaluation of rates of axillary staging and impact on adjuvant therapy in elderly women

BackgroundThe 2016 Society of Surgical Oncology Choosing Wisely guidelines recommended against routine sentinel lymph node biopsy in women ≥70 years old with favorable, early-stage breast cancer, as sentinel lymph node biopsy does not decrease recurrence or mortality in these patients. This study’s objective was to evaluate the use of sentinel lymph node biopsy and its effect on management in elderly patients.MethodsA retrospective analysis of female patients ≥70 years old with stage I–II, clinically node-negative, hormone-receptor positive, HER2-negative disease undergoing upfront breast cancer surgery between 2017 and 2019. Primary outcome was rate of sentinel lymph node biopsy. Secondary outcome was effect of sentinel lymph node biopsy on adjuvant therapy.ResultsIn total, 142 patients were included. Median age was 76 (interquartile range 73–81), and 71.8% underwent lumpectomy. On final pathology, 57.7% had invasive ductal carcinoma, and median tumor size was 15 mm (interquartile range 10–24.3). A total of 118 patients (83.1%) underwent sentinel lymph node biopsy; of these, 27 (22.9%) were positive for N1mi (7 patients) or N1a disease (20 patients). On multivariate regression analysis, patients undergoing sentinel lymph node biopsy were more likely to be younger (odds ratio 0.87, 95% confidence interval 0.78–0.95). The major risk factor for sentinel lymph node biopsy positivity was lymphovascular invasion (odds ratio 13.4, 95% confidence interval 4.57–40.1). Patients with sentinel lymph node biopsy positivity were more likely to receive local adjuvant radiation therapy (odds ratio 4.66, 95% confidence interval 1.49–16.8) and tended to receive more adjuvant regional radiation therapy (75.0% if sentinel lymph node biopsy positive compared with 15.3% if sentinel lymph node biopsy negative, P < .001).ConclusionDespite the 2016 Choosing Wisely guidelines, more than 80% of patients ≥70 years old underwent sentinel lymph node biopsy at our institution. If sentinel lymph node biopsy was positive, this is associated with over 4-fold higher rates of adjuvant radiation therapy.     

Assessment of hospital quality and safety standards among Medicare beneficiaries undergoing surgery for cancer

BackgroundWe sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer.MethodsStandard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition.ResultsAmong 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio = 0.83, 95% confidence interval: 0.76–0.89), prolonged duration of stay (odds ratio = 0.89, 95% confidence interval: 0.82–0.97), and higher odds of experiencing textbook outcome (odds ratio = 1.12, 95% confidence interval: 1.06–1.19). Patients undergoing surgery for lung (odds ratio = 1.19, 95% confidence interval: 1.10–1.30) and pancreatic cancer (odds ratio = 1.37, 95% confidence interval: 1.21–1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio = 1.16, 95% confidence interval: 0.90–1.48) or rectal cancer (odds ratio = 1.11, 95% confidence interval: 0.98–1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes.ConclusionQuality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.     

Surgical indication for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm

BackgroundIn intraductal papillary mucinous neoplasm, a mural nodule ≥5 mm is an important predictor of malignancy. Surgical indication is less clear in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. This is a retrospective study evaluating predictors of high-grade dysplasia or invasive intraductal papillary mucinous carcinoma for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm.MethodsAmong consecutive patients who underwent surgery for intraductal papillary mucinous neoplasm between 1999 and 2018, 174 had intraductal papillary mucinous neoplasm with mural nodule ≥5 mm (mural nodule[+] ≥5 mm group). The remaining 155 patients had intraductal papillary mucinous neoplasm but did not have mural nodule ≥5 mm: 24 patients with mural nodule <5 mm (mural nodule[+] <5 mm group) and 131 patients without mural nodule (mural nodule[–] group). We investigated predictors of high-grade dysplasia or invasive intraductal papillary mucinous neoplasm in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm.ResultsThe frequency of high-grade dysplasia invasive intraductal papillary mucinous neoplasm was significantly higher in the mural nodule(+) ≥5 mm group (87.4%) than in the mural nodule(+) <5 mm group (37.5%, P < .001) and mural nodule(–) group (45.0%, P < .001). However, frequency was not significantly different between mural nodule(+) <5 mm and mural nodule(–) groups (P = .494). Multivariate analysis showed three independent predictors of high-grade dysplasia invasive intraductal papillary mucinous carcinoma in intraductal papillary mucinous neoplasm without mural nodule ≥5 mm: branch cyst ≥40 mm (P = .038, odds ratio 3.704; 95% confidence interval, 1.075?12.821), positive cytology of pancreatic juice (P = .039, odds ratio 16.792; 95% confidence interval, 1.152?244.744), and carcinoembryonic antigen in pancreatic juice ≥30 mg/mL (P < .001, odds ratio 14.925; 95% confidence interval, 4.525?50.0).ConclusionFor cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm, large cysts, positive cytology of the pancreatic juice, and high levels of carcinoembryonic antigen in pancreatic juice may be useful to determine surgical indication, although further studies are needed to confirm these results.     

Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury

ObjectiveThe detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI.MethodsThis retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients.ResultsA total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06–8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08–9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01–1.04; P = 0.002) were independent risk factors for concomitant intracranial injury.ConclusionsEmergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.     

Higher glycosylated hemoglobin levels increase the risk of overactive bladder syndrome in patients with type 2 diabetes mellitus

Objectives: To assess overactive bladder and its component symptoms among patients with type 2 diabetes mellitus and to explore whether higher glycosylated hemoglobin and other factors increase the risk of overactive bladder symptoms. Methods: A total of 279 diabetes mellitus patients from our outpatient clinic, and 578 age‐ and sex‐matched subjects without diabetes mellitus from public health centers were enrolled from May to September of 2010. The collected data included overactive bladder and its component symptoms measured by using the Overactive Bladder Symptom Score, and collecting demographic and clinical data. Overactive bladder was defined as total Overactive Bladder Symptom Score ≥3 and urgency score ≥2 (once a week or more). Results: Diabetes mellitus patients had a significantly higher proportion of overactive bladder symptoms/urgency compared with the controls (28.0% vs 16.3%, odds ratio 2.03, 95% confidence interval 1.44–2.86), as well as nocturia (48.0% vs 39.1%, odds ratio 1.44, 95% confidence interval 1.08–1.93). There were no significant effects of diabetes mellitus on urge urinary incontinence (14.0% vs 10.9%, odds ratio 1.32, 95% confidence interval 0.86–2.04) and daytime frequency (26.9% vs 32.4%, odds ratio 0.77, 95% confidence interval 0.56–1.05). After adjusting for all variables, high glycosylated hemoglobin levels were significantly associated with overactive bladder/urgency (odds ratio 1.24, 95% confidence interval 1.06–1.45), urge urinary incontinence (odds ratio 1.20, 95% confidence interval 1.00–1.45) and nocturia (odds ratio 1.17, 95% confidence interval 1.01–1.35). Conclusions: Patients with type 2 mellitus present more overactive bladder symptoms/urgency and nocturia than controls. Among diabetic patients, higher glycosylated hemoglobin level represents an independent predictor of overactive bladder /urgency, urge urinary incontinence and nocturia.     

Predictive factors of complications in revisional gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry

BackgroundRoux-en-Y gastric bypass is the most common procedure for revisional bariatric surgery. This study is an analysis of revisional gastric bypass operations (rGBP) compared with primary gastric bypass (pGBP) performed in Sweden between 2007 and 2016.ObjectiveThe aim was to compare the incidence of adverse events in primary and revisional gastric bypass surgery and to identify predictive factors of intraoperative, early, and late complications in revisional gastric bypass surgery.SettingForty-four hospitals.MethodsRegistered study from the Scandinavian Obesity Surgery Registry. The study group (rGBP) comprised 1795 patients, and the control group (pGBP) comprised 46,055 patients.ResultsMedian follow-up time was 28 months. The rate of open procedures was significantly higher in the rGBP group (39.1% versus 2.4%; P < .001) decreasing from 70.8% in 2007 to 8.5% in 2016. Intraoperative complications (15.5% versus 3.0%, P < .001), early complications (24.6% versus 8.7%; P < .001), and late complications (17.7% versus 8.7%; P < .001) occurred more often in the rGBP group. Open access in revisional surgery was an independent risk factor for intraoperative complications (odds ratio 3.87; 95% confidence interval: 2.69–5.57, P < .001), early complications (odds ratio 2.08; 95% confidence interval: 1.53–2.83, P < .001), and late complications (odds ratio 1.91; 95% confidence interval: 1.31–2.78, P = .001). Indication for revision or type of index operation were not associated with complications.ConclusionRGBP was associated with a higher incidence of intraoperative, early, and late complications compared with pGBP. Open access in revisional surgery was predictive of complications regardless of the index operation or indication for revision.     

Mortality in Older Patients with Breast Cancer Undergoing Breast Surgery: How Low is “Low Risk”?

Background

Breast surgery carries a low risk of postoperative mortality. For older patients with multiple comorbidities, even low-risk procedures can confer some increased perioperative risk. We sought to identify factors associated with postoperative mortality in breast cancer patients ≥70 years to create a nomogram for predicting risk of death within 90 days.

Methods

Patients diagnosed with nonmetastatic invasive breast cancer (2010–2016) were selected from the National Cancer Database. Unadjusted OS was estimated using the Kaplan–Meier method. Multivariate logistic regression was used to estimate the association of age and surgery with 90-day mortality and to build a predictive nomogram.

Results

Among surgical patients ≥70 years, unadjusted 90-day mortality increased with increasing age (70–74 = 0.4% vs. ≥85 = 1.6%), comorbidity score (0 = 0.5% vs. ≥3 = 2.7%), and disease stage (I = 0.4% vs. III = 2.7%; all p < 0.001). After adjustment, death within 90 days of surgery was associated with higher age (≥85 vs. 70–74: odds ratio [OR] 3.16, 95% confidence interval [CI] 2.74–3.65), comorbidity score (≥3 vs. 0: OR 4.79, 95% CI 3.89–5.89), and disease stage (III vs. I: OR 4.30, 95% CI 3.69–5.00). Based on these findings, seven variables (age, gender, comorbidity score, facility type, facility location, clinical stage, and surgery type) were selected to build a nomogram; estimates of risk of death within 90 days ranged from <1 to >30%.

Conclusions

Breast operations remain relatively low-risk procedures for older patients with breast cancer, but select factors can be used to estimate the risk of postoperative mortality to guide surgical decision-making among older women.

     

End-organ effects of primary hyperparathyroidism: A population-based study

Background

Patients with primary hyperparathyroidism are at risk for skeletal and renal end-organ damage.

Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study

BackgroundAltered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function.MethodPatients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy.ResultsOut of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively).ConclusionParathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.     

Hyperparathyroidism at 1 year after kidney transplantation is associated with graft loss

BackgroundHyperparathyroidism persists in many patients after kidney transplantation. The purpose of this study was to evaluate the association between post-transplant hyperparathyroidism and kidney transplantation outcomes.MethodsWe identified 824 participants from a prospective longitudinal cohort of adult patients who underwent kidney transplantation at a single institution between December 2008 and February 2020. Parathyroid hormone levels before and after kidney transplantation were abstracted from medical records. Post-transplant hyperparathyroidism was defined as parathyroid hormone level ≥70 pg/mL 1 year after kidney transplantation. Cox proportional hazards models were used to estimate the adjusted hazard ratios of mortality and death-censored graft loss by post-transplant hyperparathyroidism. Models were adjusted for age, sex, race/ethnicity, college education, parathyroid hormone level before kidney transplantation, cause of kidney failure, and years on dialysis before kidney transplantation. A Wald test for interactions was used to evaluate the risk of death-censored graft loss by age, sex, and race.ResultsOf 824 recipients, 60.9% had post-transplant hyperparathyroidism. Compared with non-hyperparathyroidism patients, those with post-transplant hyperparathyroidism were more likely to be Black (47.2% vs 32.6%), undergo dialysis before kidney transplantation (86.9% vs 76.6%), and have a parathyroid hormone level ≥300 pg/mL before kidney transplantation (26.8% vs 9.5%) (all P < .001). Patients with post-transplant hyperparathyroidism had a 1.6-fold higher risk of death-censored graft loss (adjusted hazard ratio = 1.60, 95% confidence interval: 1.02–2.49) compared with those without post-transplant hyperparathyroidism. This risk more than doubled in those with parathyroid hormone ≥300 pg/mL 1 year after kidney transplantation (adjusted hazard ratio = 4.19, 95% confidence interval: 1.95–9.03). The risk of death-censored graft loss did not differ by age, sex, or race (all P_interaction > .05). There was no association between post-transplant hyperparathyroidism and mortality.ConclusionThe risk of graft loss was significantly higher among patients with post-transplant hyperparathyroidism when compared with patients without post-transplant hyperparathyroidism.     

Damage control orthopedics and decreased in-hospital mortality: A nationwide study

IntroductionWhile various strategies of fracture fixation in trauma victims have been discussed, the effect of damage control orthopedics (DCO) on significant clinical outcome is inconclusive. We examined the mortality of patients managed with DCO, comparing those without DCO, using a nationwide trauma database.Patients and MethodsWe retrospectively identified patients with extremity injury, defined as patients with an Abbreviated Injury Scale (AIS) of ≥2 in an upper or lower extremity, in the database that included more than 200 major hospitals from 2004 to 2016. We included those who were age ≥15 years and underwent ORIF. Patients with missing survival data or invalid vital signs at hospital arrival were excluded. Patient data were divided into DCO or non-DCO groups, and propensity scores were developed to estimate the probability of being assigned to the DCO group, using multivariate logistic regression analyses adjusted for known survival predictors, such as age, vital signs at arrival, Abbreviated Injury Scale in extremity, ISS, presence of vascular injury, surgical procedure before fracture treatment, and transfusion requirement. The primary outcome, in-hospital mortality, was compared between the two groups after propensity score matching. Survival analyses were performed, and hazard ratio was adjusted according to age, systolic blood pressure on arrival, and Injury Severity Score.ResultsOf the 19,319 patients included in this study, 4407 (22.8%) underwent DCO. After the propensity score matching, 3858 pairs were selected. In-hospital mortality was significantly lower among patients in the DCO than those in the non-DCO groups (40 [1.0%] vs. 66 [1.7%]; odds ratio = 0.60; 95% confidence interval [CI] = 0.41–0.89; P = 0.01). Survival analyses showed that DCO was independently associated with decreased mortality in patients with extremity injury (adjusted hazard ratio = 0.30; 95% CI = 0.20–0.46; P < 0.01).ConclusionsDCO was associated with decreased in-hospital mortality in patients with major fractures. Further clinical study on DCO by selecting patient population should be considered eventually to develop an appropriate strategy for major fractures.     

Neuropsychologic changes in primary hyperparathyroidism after parathyroidectomy from a dual-institution prospective study

BackgroundThe impact of parathyroidectomy on neuropsychiatric symptoms in primary hyperparathyroidism remains poorly defined. The validated scales Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 can be used to assess depression and anxiety, respectively. Our aim was to prospectively characterize the changes in neuropsychiatric symptoms after parathyroidectomy.MethodsPatients undergoing parathyroidectomy and thyroidectomy (control) from two institutions between 2014 and 2019 were prospectively administered a questionnaire assessing neuropsychiatric symptoms before and after surgery. Paired t tests compared preoperative with postoperative neuropsychiatric symptoms and t tests compared differences in neuropsychiatric symptoms between parathyroidectomy and thyroidectomy.ResultsA total of 244 patients underwent parathyroidectomy and 161 underwent thyroidectomy. We observed improvement in neuropsychiatric symptoms after parathyroidectomy (6.2 [5.0–7.4], P < .01). Preoperatively, neuropsychiatric symptoms were more prevalent in patients undergoing parathyroidectomy when compared with thyroidectomy (11.2 ± 11.5 vs 7.5 ± 8.2, P < .01); however, after surgery there was no difference between the two groups (5.1 ± 7.1 vs 5.4 ± 7.2, P = .59). Preoperatively, 27.5% and 18.0% of patients endorsed moderate to severe depression and anxiety, which fell to 8.2% and 5.3%, respectively, (P < .01) after surgery.ConclusionPatients undergoing parathyroidectomy showed significant improvement in neuropsychiatric symptoms after surgery. Neuropsychiatric symptoms are more prevalent in patients with primary hyperparathyroidism. Neuropsychiatric symptoms should be assessed in all patients with primary hyperparathyroidism and should be considered a relative indication for parathyroidectomy.     

Development and validation of a multivariable prediction model in pediatric liver transplant patients for predicting intensive care unit length of stay

Background

Liver transplantation is the life-saving treatment for many end-stage pediatric liver diseases. The perioperative course, including surgical and anesthetic factors, have an important influence on the trajectory of this high-risk population. Given the complexity and variability of the immediate postoperative course, there would be utility in identifying risk factors that allow prediction of adverse outcomes and intensive care unit trajectories.

Aims

The aim of this study was to develop and validate a risk prediction model of prolonged intensive care unit length of stay in the pediatric liver transplant population.

Methods

This is a retrospective analysis of consecutive pediatric isolated liver transplant recipients at a single institution between April 1, 2013 and April 30, 2020. All patients under the age of 18 years receiving a liver transplant were included in the study (n = 186). The primary outcome was intensive care unit length of stay greater than 7 days.

Results

Recipient and donor characteristics were used to develop a multivariable logistic regression model. A total of 186 patients were included in the study. Using multivariable logistic regression, we found that age < 12 months (odds ratio 4.02, 95% confidence interval 1.20–13.51, p = .024), metabolic or cholestatic disease (odds ratio 2.66, 95% confidence interval 1.01–7.07, p = .049), 30-day pretransplant hospital admission (odds ratio 8.59, 95% confidence interval 2.27–32.54, p = .002), intraoperative red blood cells transfusion >40 mL/kg (odds ratio 3.32, 95% confidence interval 1.12–9.81, p = .030), posttransplant return to the operating room (odds ratio 11.45, 95% confidence interval 3.04–43.16, p = .004), and major postoperative respiratory event (odds ratio 32.14, 95% confidence interval 3.00–343.90, p < .001) were associated with prolonged intensive care unit length of stay. The model demonstrates a good discriminative ability with an area under the receiver operative curve of 0.888 (95% confidence interval, 0.824–0.951).

Conclusions

We develop and validate a model to predict prolonged intensive care unit length of stay in pediatric liver transplant patients using risk factors from all phases of the perioperative period.     

Routine blood tests as predictors of mortality in hip fracture patients

ObjectiveThe aim of this study was to assess the evidence for the association between different biochemical markers at admission and mortality through a meta-analysis.Data sourcesPubMed-, Embase-, Cochran Library and the Web of Knowledge were searched for cohort studies.Study selectionEligible studies were observational studies with a study population larger than 150 subjects, a mean age above 60 years and a study duration below 730 days.Data extractionCharacteristics of studies and outcomes of all-cause mortality were extracted from the retrieved articles. Data were pooled across studies for the individual biomarker using random- or fixed-effect analysis.Data synthesis15 eligible studies of 5 different markers on mortality were studied. The following markers were found to be of prognostic value on mortality in hip fracture patients: low haemoglobin (odds ratio, 2.78; 95% confidence interval, 2.17–3.55; P < 0.00001, 3148 subjects included), low total lymphocyte count, TLC (odds ratio, 2.60; 95% confidence interval, 1.61–4.20; P < 0.00001, 1689 subjects included), low albumin (odds ratio, 1.83; 95% confidence interval, 1.31–2.56; P = 0.0004, 1680 subjects included), low albumin/low TLC (odds ratio, 3.00; 95% confidence interval, 1.81–4.99; P < 0.0001, 704 subjects included), low albumin/high TLC (odds ratio, 3.39; 95% confidence interval, 1.83–6.29; P = 0.0001, 704 subjects included), high creatinine (odds ratio, 1.58; 95% confidence interval, 1.25–1.99; P = 0.0001, 3761 subjects included), and high PTH (odds ratio, 15.43; 95% confidence interval, 3.60–66.14; P = 0.0002, 525 subjects included).ConclusionBiochemical markers at admission are valid predictors of mortality in hip fracture patients.     

Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery

BackgroundData on predictors of nonroutine discharge among patients undergoing hepatopancreatic surgery remain poorly defined. We sought to define factors associated with nonroutine discharge to home with home health care or to a skilled nursing facility or intermediate care facility and determine the impact of discharge destination on outcomes after hepatopancreatic surgery.MethodsThe Nationwide Readmissions Database was queried for individuals who underwent hepatopancreatic surgeries 2010–2014 and were discharged home with home health care or to a skilled nursing facility/intermediate care facility.ResultsA total of 42,189 patients underwent hepatopancreatic surgery. Of those, 2,825 (6.70%) were discharged to a skilled nursing facility or intermediate care facility, whereas 10,925 (25.9%) were discharged with home health care. A majority of patients underwent major hepatectomy (N = 14,516, 34.4%) or minor pancreatectomy (N = 13,824, 32.8%). Compared with patients discharged home, patients discharged to a skilled nursing facility or intermediate care facility were older (median age: 60 years, interquartile range: 50–68 vs 73, 67–79) and had more comorbidities (median score: 3, interquartile range: 1–8 vs 4, interquartile range: 2–8; P < .001). Type of operative procedure was not associated with discharge to a skilled nursing facility versus with home health care. Rather, patients with extreme loss of function, based on preoperative assessment, had 2.76 times higher odds of discharge to a skilled nursing facility or intermediate care facility versus with home health care (odds ratio 2.76, 95% confidence interval 1.98–3.85). Similarly, older (odds ratio 1.06, 95% confidence interval 1.06–1.07) and female patients (odds ratio 1.37, 95% confidence interval 1.25–1.51) were more likely to be discharged to a skilled nursing facility or intermediate care facility versus with home health care.ConclusionOne in four patients undergoing hepatopancreatic surgery were readmitted within 90 days of surgery. Age, severity of comorbidities, and perioperative course, including incidence of complications, were associated with nonroutine discharge.