Search

Background: In a first step toward standardization, the Primary Aldosteronism Surgical Outcomes investigators introduced consensus criteria defining the clinical outcomes after adrenalectomy for primary aldosteronism. Within this retrospective cohort study, we evaluated the use of these consensus criteria in daily clinical practice in 16 centers in Europe, Canada, Australia, and the United States.Methods: Patients who underwent unilateral adrenalectomy for primary aldosteronism between 2010 and 2016 were included. Patients with missing data regarding preoperative or postoperative blood pressure or their defined daily dose were excluded. According to the Primary Aldosteronism Surgical Outcomes criteria, patients were classified as complete, partial, or absent clinical success.Results: A total of 380 patients were eligible for analysis. Complete, partial, and absent clinical success was achieved in 30%, 48%, and 22%, respectively. Evaluation of the Primary Aldosteronism Surgical Outcomes criteria showed that in 11% and 47% of patients with partial and absent clinical success, this classification was incorrect or debatable (16% of the total cohort). This concept of a "debatable classification of success" was due mainly to the cutoff of >= 20 mmHg used to indicate a clinically relevant change in systolic blood pressure and the use of percentages instead of absolute values to indicate a change in defined daily dose.Conclusion: Although introduction of the Primary Aldosteronism Surgical Outcomes consensus criteria induced substantial advancement in the standardization of postoperative outcomes, our study suggests that there is room for improvement in the concept for success given the observed limitations when the criteria were tested within our international cohort. In line, determining clinical success remains challenging, especially in patients with opposing change in blood pressure and defined daily dose. (C) 2019 Elsevier Inc. All rights reserved.

Background Cure of hypertension after adrenalectomy for primary aldosteronism is no certainty and therefore preoperative patient counseling is essential. The Primary Aldosteronism Surgical Outcome (PASO) Score is a useful prediction model with an area under the curve (AUC) of 0.839. The PASO Score includes ‘Target Organ Damage’ (TOD) (i.e., left ventricular hypertrophy and/or microalbuminuria), which is often unavailable during preoperative counseling and might therefore limit its use in clinical practice. We hypothesized that the PASO score would still be useful if TOD is unknown at time of counseling. Therefore, we aimed to examine the predictive performance of the simplified PASO Score, without taking TOD into account. Materials and methods In this retrospective cohort study, patients who underwent unilateral adrenalectomy between 2010 and 2016 in 16 medical centers from North America, Europe and Australia were included. TOD was unknown in our database and therefore assigned as absent. Patients were classified as complete, partial or absent clinical success using the PASO consensus criteria. Results A total of 380 (73.9%) patients were eligible for analysis. Complete, partial and absent clinical success were observed in 29.5%, 55.8% and 14.7% of patients, respectively. The simplified PASO Score had an AUC of 0.730 (95% confidence interval 0.674–0.785) in our total cohort. Conclusion Without taking TOD into account, the simplified PASO Score had a lower predictive value as compared to the original derivation cohort. Ideally, the complete PASO Score should be used, but when data on TOD are not readily available, the simplified PASO Score is a useful and reasonable alternative., Highlights • We aimed to examine the predictive performance of the PASO Score, without taking ‘target organ damage’ (TOD) into account. • This simplified PASO Score had a lower predictive value as compared to the PASO Score in the original derivation cohort. • The simplified PASO Score increases the applicability of the model and is reasonable for clinicians to use in daily practice. • Ideally, the complete PASO Score should be used, but the simplified PASO Score is a useful and reasonable alternative.

OBJECTIVE To examine the evolution of an academic endocrine surgeon's practice over time. SUMMARY BACKGROUND Amid growing recognition that surgical volume and specialization are linked to better outcomes, endocrine surgery is one of the youngest fields to develop its own formal fellowship training program. However, 3 decades after the emergence of endocrine surgery as a distinct specialty, the medical community and public still have a limited understanding of endocrine surgeons and what they do. METHODS We performed a cross-sectional analysis of endocrine surgeons identified in the Faculty Practice Solutions Center Database from 2014 to 2017. Trends in annual number of endocrine surgeries performed, number of all surgeries performed, total work relative value units generated, and patient payer mix stratified by years of practice were evaluated. RESULTS One hundred thirty-nine endocrine surgeons practicing in 103 institutions over 4 years were analyzed. The proportion of endocrine-specific operations increases over time. A typical academic endocrine surgeon meets the high-volume threshold for thyroidectomies early in their career, but does not reach the thresholds for parathyroidectomies or adrenalectomies until after 4 years. Increased productivity as reflected by adjusted work relative value units does increase over the first 15 years of practice, but also decreases as the proportion of endocrine-specific practice increases. The greatest proportion of endocrine surgeons' patients are insured by commercial plans (46%-50%), and payer mix is stable across all levels of practice. CONCLUSIONS Although endocrine surgeons perform a high-volume of endocrine-specific operations, practice patterns are heterogeneous and suggest that most surgeons have to grow their endocrine-specific practice over time.

PurposeSerum calcium and parathyroid hormone levels are the primary means of evaluating patients for hyperparathyroidism. Whether there are differences in urinary parameters between stone formers with and those without hyperparathyroidism is controversial. In this study we identify urinary parameters that predict primary hyperparathyroidism.Materials and methodsFrom 2001 to 2010 a total of 1,190 adult, noncystine stone forming patients underwent urinary metabolic stone evaluation. Of these patients 34 (3%) underwent parathyroidectomy for primary hyperparathyroidism. Urinary parameters were evaluated as predictors of primary hyperparathyroidism. The most accurate combination of serum and urinary tests and their cutoffs were determined.ResultsStone forming patients with primary hyperparathyroidism were more likely to be women and had higher urinary calcium excretion. Hypercalciuria (aOR 4.38), supersaturation calcium oxalate greater than 10 (aOR 4.27), supersaturation calcium phosphate greater than 2 (aOR 3.64), calcium per kg greater than 4 mg/kg (aOR 8.03) and calcium-to-creatinine ratio greater than 150 mg/gm (aOR 7.07) were significant predictors of primary hyperparathyroidism in separate multivariate models after adjustment. The best accuracy was determined using serum calcium and parathyroid hormone levels with our laboratory cutoffs (AUC 0.984) with a sensitivity of 87%, specificity of 99%, positive predictive value of 79% and negative predictive value of 99.5%. No other factor(s) improved diagnostic accuracy or could replace parathyroid hormone level.ConclusionsGreater urinary calcium excretion predicted primary hyperparathyroidism. Serum calcium with parathyroid hormone level was the most accurate test for primary hyperparathyroidism. No other serum or urinary parameter improved diagnostic accuracy or could replace parathyroid hormone. There were no obvious cutoffs for any of the urinary parameters that reliably differentiated cases of hyperparathyroidism.

Background Although cervical endocrine operations are classified as clean cases, and prophylactic antibiotics (pABX) are generally not indicated, practice patterns vary. Study Design We distributed an Internet-based survey to all members of the American and International Associations for Endocrine Surgeons. As a second component of our study, University of California San Francisco hospital records were queried for all readmissions or reoperations within 30 days after thyroidectomy, parathyroidectomy, or neck dissections between January 1, 1999 and December 30, 2007. Results Of the 275 endocrine surgeons who responded, 62% "almost never" used pABX and 26.2% administered pABX "almost always." Surgeons' annual caseload (p = 0.21), their experience with past patients who had minor (p = 0.33) or severe (p = 0.83) surgical site infections (SSI) or adverse reactions to antibiotics (p = 0.78) were not associated with their likelihood to prescribe pABX. In the previous 3 years, most surgeons reported treating patients with minor SSIs, and 30% of surgeons treated more than 1 severe SSI. Surgeons who worked in community hospitals were more likely to give pABX than were surgeons in affiliated or university hospitals (49.6% vs 31.8% and 24.5%, respectively (p = 0.04). Unlike European (8.8%) or American surgeons (27.9%), surgeons in Asia were most likely to give pABX "almost always" (58.3%, p=0.0001). Two-thirds of surgeons would not want antibiotics if they, themselves, needed a cervical operation. Five of the 4,541 patients (0.11%) who underwent cervical operations were readmitted for infectious complications. Conclusions Infectious complications after endocrine cervical operations are rare and the use of preoperative antibiotics varies widely. Prescribing behavior appears dogmatic in that 90% of surgeons give preoperative antibiotics almost always or almost never.

Prophylactic thyroidectomy can be curative for patients with hereditary medullary thyroid cancer (MTC) caused by RET proto-oncogene mutations. Calcitonin is a sensitive tumor marker used to follow patients. We suggest that thyroglobulin (Tg) levels should also be monitored postoperatively in these patients.We reviewed patients with RET mutations who underwent prophylactic thyroidectomy between 1981 and 2011 at an academic endocrine surgery center. Patients were excluded if they had no postoperative Tg levels recorded.Of the 22 patients who underwent prophylactic thyroidectomy, 14 were included in the final analysis. The average age at thyroidectomy was 9.8 years (range, 4-29). Tg levels were detectable 1.5 months to 31 years postoperatively in 11 patients (79%), all of whom were15 years old at thyroidectomy. Median thyroid-stimulating hormone (TSH) was 2.5 mIU/L and 13.4 mIU/L in patients with undetectable and detectable Tg, respectively. Of those with detectable Tg, 5 had cervical ultrasonographic examination: Two showed no residual tissue in the thyroid bed, and 3 showed remnant thyroid tissue.Tg levels can identify patients with remnant thyroid tissue after prophylactic thyroidectomy. Ultrasonography can determine whether thyroid tissue remains posterolaterally that is at risk of MTC recurrence. Maintaining normal TSH may prevent growth of remaining thyroid follicular cells.

Author(s): Mathur, A; Moses, Willieford; Rahbari, R; Khanafshar, E; Duh, QY; Clark, O; Kebebew, E

Background The helix-loop transcription factor (Id1) protein inhibits differentiation, enhances cell proliferation and is required for cell-cycle progression. Id1 is highly expressed in a variety of tumour-derived cell lines, increases following mitogenic stimuli and is overexpressed in some human neoplasms. It was therefore reasoned that the Id1 gene may play a role in medullary thyroid carcinogenesis. Methods Id1 protein expression in human medullary thyroid cancer (MTC) and corresponding normal thyroid tissue was determined by Id1 immunohistochemistry. Calcitonin immunohistochemistry was used to determine the cellular localization of Id1 immunostaining. In a well characterized human MTC cell line (TT), the effects of growth stimulation (with serum) and redifferentiation (with phorbol esters) on Id1 expression were determined by Northern blot analysis. Results Id1 immunostaining intensity in MTC (n = 9; six sporadic MTCs, two familial MTCs and one multiple endocrine neoplasia type 2A MTC) was moderate to strong whereas in the corresponding normal thyroid tissues (n = 9) it was absent or faint in the C cells and follicular cells. Id1 immunostaining was significantly higher in MTC than the corresponding normal thyroid tissue based on the percentage of positive cells and immunostaining intensity (P = 0·002, rank sum test). The 1·2-kilobase Id1 transcript was expressed in the TT cell line under basal culture conditions. Interestingly, Id1 messenger RNA (mRNA) expression was markedly upregulated (4·0 fold) following growth stimulation with 10 per cent fetal bovine serum. In addition, phorbol ester (which is known to induce redifferentiation of the TT cell line) downregulated Id1 mRNA expression in the TT cell line. Conclusion Id1 is overexpressed in MTC. Furthermore, increased Id1 expression is associated with an enhanced proliferative potential in MTC. The inappropriate proliferation and dedifferentiation of the C cells that lead to MTC, at least in part, may be regulated by the Id1 gene.