A critical analysis of 33 patients with substernal goiter surgically treated by neck incision

The possibility of needing a combined access, with neck and chest incisions makes the treatment of substernal goiter a challenge both in the pre-op and the intraoperative. We hereby, discuss a standardization of the surgical technique to minimize the need for a chest approach, making the substernal goiter a surgically treatable disease, through a single neck incision, and with low indices of complication. AIM: to assess the substernal goiter surgically approach through a neck incision and to analyze the surgical complications. MATERIALS AND METHODS: we carried out a historical cohort by retrospective analysis of the charts of patients submitted to thyroidectomy, and 33 of them (10.4%) had substernal goiter. RESULTS: all 33 patients were surgically treated through a neck incision without the need for sternotomy. We did not observe definitive lesions in the inferior laryngeal nerve or definitive hypoparathyroidism. Only 2 patients had recurrent nerve paresis; and 2 patients were re-operated because of a neck hematoma. CONCLUSION: patients with substernal goiter can be safely treated surgically through a single neck incision, bearing low complication rates.A possibilidade de ser necessário um acesso combinado, com uma incisão cervical e outra torácica, torna o tratamento do bócio mergulhante um desafio tanto no pré quanto no intra-operatório. Discutimos uma padronização da técnica cirúrgica para minimizar a necessidade da abordagem torácica, tornando o bócio mergulhante uma patologia tratável cirurgicamente, por uma única incisão cervical, e com baixos índices de complicações. OBJETIVO: Avaliar a abordagem cirúrgica do bócio mergulhante por cervicotomia e analisar as complicações cirúrgicas. MATERIAL E MÉTODOS: Foi realizada uma coorte histórica com corte transversal por análise retrospectiva dos prontuários de pacientes submetidos à tireoidectomia no período de maio de 2002 a julho de 2007. Um total de 316 pacientes foi submetido à tireoidectomia sendo 33 (10,4%) por bócio mergulhante. RESULTADOS: Todos os 33 pacientes foram tratados cirurgicamente por via cervical sem necessidade de esternotomia. Não foram observadas lesões definitivas de nervo laríngeo inferior ou hipoparatireoidismo definitivo. Apenas 2 pacientes apresentaram paresia de nervo recorrente e 2 pacientes foram reabordados por hematoma cervical. CONCLUSÃO: Pacientes com bócio mergulhante podem ser tratados cirurgicamente por uma única incisão cervical com segurança e baixos índices de complicação.UNIFESPUNIFESPSciEL

Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy

Introduction:Hyperparathyroidism is an expected metabolic consequence of chronic kidney disease (CKD). Ectopic and/or supernumerary parathyroid glands (PT) may be the cause of surgical failure in patients undergoing total parathyroidectomy (PTX).Aim:To define the locations of ectopic and supernumerary PT in patients with renal hyperparathyroidism and to correlate intraoperative findings with preoperative tests.Materials and methods:A retrospective study was conducted with 166 patients submitted to PTX. The location of PT during surgery was recorded and classified as eutopic or ectopic. The preoperative localizations of PT found by ultrasonography (USG) and Tc99m-Sestamibi scintigraphy (MIBI) were subsequently compared with intraoperative findings.Results:In the 166 patients studied, 664 PT were found. Five-hundred-seventy-seven (86.4%) glands were classified as eutopic and 91(13.6%) as ectopic. Eight supernumerary PT were found. The most common sites of ectopic PT were in the retroesophageal and thymic regions. Taken together, USG and MIBI did not identify 56 (61.5%) ectopic glands. MIBI was positive for 69,7% of all ectopic glands located in the mediastinal and thymic regions.Conclusion:The presence of ectopic and supernumerary PT in patients with renal hyperparathyroidism is significant. Although preoperative imaging tests did not locate most of ectopic glands, MIBI may be important for identifying ectopic PT in the mediastinal and thymic regions.Introdução:O hiperparatireoidismo é uma consequência metabólica esperada na doença renal crônica (DRC). Paratireoides (PT) ectópicas e/ou supranumerárias podem ser causa de falha cirúrgica nos pacientes submetidos à paratireoidectomia total (PTX).Objetivo:Definir cirurgicamente a localização das PT, em pacientes com hiperparatireoidismo associado à DRC, e correlacionar esses achados com os exames pré-operatórios.Materiais e métodos:Foi conduzido um estudo retrospectivo com 166 pacientes submetidos à PTX. A localização das PT no intraoperatório foi registrada, sendo classificada como tópica ou ectópica. A localização pré-operatória, definida pela ultrassonografia (USG) e pela cintilografia Tc99m-Sestamibi (MIBI), foi comparada com aos achados cirúrgicos.Resultados:Nos 166 pacientes, foram identificadas 664 PT. Foram classificadas como tópicas e ectópicas 577 (86,4%) e 91(13,6%) glândulas, respectivamente. Oito PT supranumerárias foram encontradas (7 tópicas e 1 ectópica). As localizações mais comuns de PT ectópicas foram as regiões retroesofágica e tímica. Associadas, a USG e a MIBI não identificaram 56 glândulas (61,5%) ectópicas. Entretanto, a MIBI foi positiva para 69,7% daquelas localizadas nas regiões tímicas e mediastinal.Conclusão:A presença de glândulas ectópicas e supranumerárias em pacientes com hiperparatireoidismo associado à DRC é significativa. Os exames de imagem pré-operatórios não localizaram a maioria das glândulas ectópicas. A MIBI pode ter importância na identificação de PT nas regiões tímica e mediastinal.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Otorrinolaringologia e Cirurgia de Cabeca e PescocoUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de NefrologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Endocrinologia ClinicaUNIFESP, EPM, Depto. de Otorrinolaringologia e Cirurgia de Cabeca e PescocoUNIFESP, EPM, Depto. de NefrologiaUNIFESP, EPM, Depto. de Endocrinologia ClinicaSciEL

Planned parathyroidectomy: the new standard in hypercalcemic crisis

ABSTRACT Objective: The study sought to determine the clinical features of hyperparathyroid-induced hypercalcemic crisis (HIHC) along with treatment options and outcomes. Subjects and methods: This is a retrospective analysis of our historical cohort of patients with primary hyperparathyroidism (PHPT). Patients were divided in groups according to their calcium levels and clinical presentation. HIHC (group 1) was assumed when patients had high calcium levels and needed emergency hospitalization. Group 2 was composed of patients with calcium levels above 16 mg/dL or patients who needed hospitalization for classical PHPT symptoms. Group 3 was composed of clinically stable patients with calcium levels between 14 and 16 mg/dL, who were electively treated. Results: Twenty-nine patients had calcium levels above 14 mg/dL. HIHC group had seven patients, and initial clinical measures had good response in two patients, moderate response in one patient, and poor response in four patients. All poor responders underwent immediate surgery, and one of them died due to HIHC complications. Group 2 had nine patients, and all were successfully treated during hospitalization. Group 3 had 13 patients, and all had a successful elective surgery. Conclusion: HIHC is a life-threatening condition that requires fast clinical intervention. Surgery is the only definitive treatment and should be planned for all patients. Poor response to initial clinical measures should direct treatment toward surgery to avoid disease progression and clinical deterioration

Risk of hospitalization for heart failure in patients with type 2 diabetes newly treated with DPP-4 inhibitors or other oral glucose-lowering medications: A retrospective registry study on 127,555 patients from the Nationwide OsMed Health-DB Database

Aims Oral glucose-lowering medications are associated with excess risk of heart failure (HF). Given the absence of comparative data among drug classes, we performed a retrospective study in 32 Health Services of 16 Italian regions accounting for a population of 18 million individuals, to assess the association between HF risk and use of sulphonylureas, DPP-4i, and glitazones. Methods and results We extracted data on patients with type 2 diabetes who initiated treatment with DPP-4i, thiazolidinediones, or sulphonylureas alone or in combination with metformin during an accrual time of 2 years. The endpoint was hospitalization for HF (HHF) occurring after the first 6 months of therapy, and the observation was extended for up to 4 years. A total of 127 555 patients were included, of whom 14.3% were on DPP-4i, 72.5% on sulphonylurea, 13.2% on thiazolidinediones, with average 70.7% being on metformin as combination therapy. Patients in the three groups differed significantly for baseline characteristics: age, sex, Charlson index, concurrent medications, and previous cardiovascular events. During an average 2.6-year follow-up, after adjusting for measured confounders, use of DPP-4i was associated with a reduced risk of HHF compared with sulphonylureas [hazard ratio (HR) 0.78; 95% confidence interval (CI) 0.62-0.97; P = 0.026]. After propensity matching, the analysis was restricted to 39 465 patients, and the use of DPP-4i was still associated with a lower risk of HHF (HR 0.70; 95% CI 0.52-0.94; P = 0.018). Conclusion In a very large observational study, the use of DPP-4i was associated with a reduced risk of HHF when compared with sulphonylureas

Subtotal resection of parathyroids preserving an intact parathyroid in patients with tertiary hyperparathyroidism

O hormônio da paratireoide, denominado paratormônio (PTH), controlador da homeostase do cálcio, é sintetizado e secretado pelas glândulas paratireoides. Podem tornar-se hiperfuncionantes, gerar quantidades excessivas de PTH e determinar o quadro clínico-laboratorial denominado hiperparatireoidismo (HPT). Quando o HPT é consequência de um desequilíbrio metabólico pré-existente, ele é denominado secundário. O hiperparatireoidismo secundário (HPTS) é, desta forma, uma desordem adquirida representada pela hipersecreção das paratireoides em resposta a perturbações da homeostase do cálcio. A doença renal crônica (DRC) é uma condição frequentemente associada ao HPTS. Trata-se de uma desordem heterogênea caracterizada por graus variáveis de estímulo e supressão do PTH, estando associada a hiperplasia das glândulas paratireoides. Objetivo: O objetivo deste estudo é determinar se a paratireoidectomia subtotal com a manutenção de uma paratireoide intacta em seu leito, pode ser uma opção técnica no tratamento cirúrgico de pacientes com hiperparatireoidismo terciário. Método: O presente estudo trata-se de análise de coorte prospectiva histórica de pacientes submetidos a paratireoidectomia subtotal com a manutenção de uma glândula paratireoide intacta em seu leito, por hiperparatireoidismo terciário. Resultado: Selecionados 44 pacientes com idade variando entre 30 e 75 anos, com uma mediana de 49,5 anos para o grupo, divididos igualmente entre homens e mulheres. Tempo de tratamento conservador de 36,75 meses e tempo de hemodiálise 67,33 meses. O tempo de transplante renal foi de 42,64 meses, com valor do PTH no dia do transplante renal de 822,03 pg/mL. No dia da cirurgia o PTH foi de 170,9 pg/mL, atingindo um valor médio de 77,2 após 5 anos. O valor inicial do cálcio iônico foi de 1,47 mmol/L e um valor final de 1,29 mmol/L após 5 anos. Conclusão: A avaliação do presente estudo permite concluir que a paratireoidectomia subtotal com a manutenção de uma glândula paratireoide intacta em seu leito, é uma opção técnica segura e efetiva no tratamento cirúrgico de pacientes com hiperparatireoidismo terciário.Introduction: Parathyroid hormone (PTH), controller of calcium homeostasis, is synthesized and secreted by the parathyroid glands. They can become hyper functioning, generate excessive amounts of PTH, and determine the clinicallaboratory picture called hyperparathyroidism (HPT). When HPT is a consequence of a preexisting metabolic imbalance, it is called secondary. Secondary hyperparathyroidism (HPTS) is thus an acquired disorder represented by parathyroid hypersecretion in response to calcium homeostasis disorders. Chronic kidney disease (CKD) is a condition often associated with HPTS. It is a heterogeneous disorder characterized by varying degrees of stimulation and suppression of PTH, being associated with hyperplasia of the parathyroid glands. Objective: The aim of this study is to determine whether subtotal parathyroidectomy, keeping an intact parathyroid in its bed, may be a technical option in the surgical treatment of patients with tertiary hyperparathyroidism. Method: The present study is a historic prospective cohort analysis of patients undergoing subtotal parathyroidectomy, keeping a parathyroid gland intact in its bed, by tertiary hyperparathyroidism. Result: 44 patients aged between 30 and 75 years of age were selected, with a median of 49.5 years for the group, divided equally between men and women. Conservative treatment time was 36.75 months and hemodialysis time was 67.33 months. Renal transplantation time was 42.64 months, with PTH value on the day of renal transplantation of 822.03 pg/mL. On the day of surgery, the PTH value was 170.9 pg/mL, reaching an average value of 77.2 after 5 years. The initial value of ionic calcium was 1.47 mmol/L and a final value of 1.29 mmol/L after 5 years. Conclusion: The evaluation of the present study allows us to conclude that subtotal parathyroidectomy, keeping a parathyroid gland intact in its bed, is a safe and effective technical option in the surgical treatment of patients with tertiary hyperparathyroidism

Continuous 12-lead ST-segment monitoring improves identification of low-risk patients with chest pain and a worse in-hospital outcome

Various strategies have been proposed to improve diagnosis and triage of patients with chest pain at low risk, but uncertainty still exists on the optimal combination of diagnostic tools that should be used in this subset of patients

Macromolecular Modelling and Docking Simulations for the Discovery of Selective GPER Ligands

Estrogens influence multiple physiological processes and are implicated in many diseases as well. Cellular responses to estrogens are mainly mediated by the estrogen receptors (ER)\u3b1 and ER\u3b2, which act as ligand-activated transcription factors. Recently, a member of the G protein-coupled receptor (GPCR) superfamily, namely GPER/GPR30, has been identified as a further mediator of estrogen signalling in different pathophysiological conditions, including cancer. Today, computational methods are commonly used in all areas of health science research. Among these methods, virtual ligand screening has become an established technique for hit discovery and optimization. The absence of an established three-dimensional structure of GPER promoted studies of structure-based drug design in order to build reliable molecular models of this receptor. Here, we discuss the results obtained through the structure-based virtual ligand screening for GPER, which allowed the identification and synthesis of different selective agonist and antagonist moieties. These compounds led significant advances in our understanding of the GPER function at the cellular, tissue, and organismal levels. In particular, selective GPER ligands were critical toward the evaluation of the role elicited by this receptor in several pathophysiological conditions, including cancer. Considering that structure-based approaches are fundamental in drug discovery, future research breakthroughs with the aid of computer-aided molecular design and chemo-bioinformatics could generate a new class of drugs that, acting through GPER, would be useful in a variety of diseases as well as in innovative anticancer strategies